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EDITORIALSWastewaterRecyclingandReuseAsiswellknown,wastewatershavebeenreclaimedforagriculturaluseforcenturies.ThearticlebyFattal,etal,inthisissueoftheJournalreportsresultsofanepidemiologicalstudyoftheimpactofpoorqualitywastewatereffluentusedforirrigationofnonfoodcropsonthehealthofpeopleresidinginnearbykibbutziminIsrael.Thepracticeofusingwastewatersforirrigationiscommoninmanyaridandsemiaridareasoftheworld,includingtheUnitedStates.Currently,thereisconsiderableinterestinthepotentialhealtheffectsassociatedwiththedirectandindirecthumanconsumptionofreclaimedwastewaters.Indirecthumanconsumptionofwastewatersoccurswhensurfacewaters,particularlyriversreceivingwastewaterdischarges,areusedforwatersupply.Thesesurfacesources,alongwithanincreasingnumberofgroundwaterresources,arecontaminatedbythewastedischargesfromcommunities,industrialactivities,agriculturalandurbanrunoff,andstormwater.Usingthesesourcesofsupply,watertreatmentplantshaveproducedwaterthatisconsideredsafeforhumanuse,althoughthesefinishedwatersmaycontainlowlevelsoforganicchemicalswhichmaybepotentiallyharmfulfollowinglongtermingestion.AnearlyexampleofthedirectreuseofwastewaterforpotablepurposesoccurredinChanute,Kansasfollowingthedroughtof195257.2DuringtheperiodfromOctober14,1956throughMarch14,1957,becauseofthecriticalshortageofwater,municipalwastewatertreatmentplanteffluentwasrecycledthroughthewatertreatmentplantandintroducedintothewaterdistributionsystem.Althoughthewatermetexistingmicrobialstandards,withcontinuedrecyclingpublicacceptancedecreasedandbottledwatersalesflourished.Currently,theonlyknownsourceofdirectreuseofreclaimedwastewateristhatatWindhoek,NamibiainsouthwestAfrica,wherewastewaters,devoidoftoxicindustrialwastes,aredischargedafterextensivetreatmenttomaturationpondsbeforeadmixturewithuncontaminatedsourcewaters.Withthedevelopmentofnewtechnologiesforthetreatmentofwastewateradvancedortertiarytreatment,fosteredinpartbytheFederalWaterPollutionActof1972andSection1444oftheSafeDrinkingWaterActof1974,34extensivestudieshaveshownthattreatedwastewaterscouldbeproducedwhichmeetallofthemaximumconcentrationlimitsstipulatedinthedrinkingwaterstandards.56Thedrinkingwaterstandardsstate...priorityshouldbegiventotheselectionofthepurestsource.Pollutedsourcesshouldnotbeused...andAbatementandcontrolofpollutionwillsignificantlyaidinproducingdrinkingwater...infullcompliancewith...thesestandardsandwillbeaestheticallyacceptabletotheconsumer......IEventhoughthestandardscallforobtainingthewatersupplyfromtheleastpollutedsource,thereareareas,particularlyinthesunbelt,whicharealreadyusingwaterbeyondthecapacityoftheavailablenaturalsupplies,3andwhereitmaynotbeeconomicallyfeasibletoimportwatersofpotablequality.Intheinterestofconservingexistingwatersupplysources,reclaimedwastewatersarebeingusedforindustrialpurposes,78agriculturalcropirrigation,79urbanirrigation,,79recreationalpurposes,7andgroundwaterrecharge.4105Dependingontheextentoftreatmentreceivedbeforereuse,therearepublichealthconcernsrelatedtoeachofthesereusepractices.Theseincludemicrobialpathogensandindicators722traceorganicconstituentsandtheireffects7151923traceinorganiccontaminantsandtheireffects751922andphysicalconstituents,suchassuspendedsolidsandturbidity.7InthemostcomprehensivestudytodatetoevaluatetheeffectsonhealthofusingtreatedwastewaterforgroundwaterreplenishmentattheWhittierNarrowsGroundwaterReplenishmentPlant,theauthors24concludedthattherewerenodemonstrableormeasurableadverseeffectsoneithertheareasgroundwateroronthehealthofthepeopleingestingthewater.Roberts5indicatedthatthoseresponsibleforpossiblehealthdecisionsintheuseofreclaimedwastewaterstakeanunderstandablycautiousattitudetowardtheyetunquantifiedriskofchronichealtheffectscausedbytraceorganics.Althoughmaximumconcentrationlimitshavebeenestablishedforseveralinorganicandafeworganicpesticidesinpotablewatersupplies,56limitsformanycompounds,particularlyorganic,havenotbeenestablished.However,limitshavebeenproposedforadditionalorganiccompoundsinwater.25Maximumconcentrationlimitsareforsingleentitiesanddonotrelatetothepossibleadditive,synergistic,orantagonisticbehaviorofmanycontaminants.Californiahasbeenaleaderindevelopingstandardsforreclaimedwastewatersusedinagricultureandfortherechargeofgroundwaters.40926Inlieuofstandardsforassessingthequalityofreclaimedwastewater,Work,etal,27proposedthattreatmentatDenverbecapableofremovingtheincrementaddedtothewastethroughuse,thusreturningthewatertothequalityinitiallypresentinthewatersupplysource.This,ofcourse,wouldentailmeasurementofallknownparameters,butnotunknownsubstancescapableofinducinghealtheffectsafterlongtermconsumption.Asindicatedearlier,processesareavailabletotreatwastewaterstomeetcurrentdrinkingwaterstandards6however,theextentoftreatmentisafunctionofcost.Removaloftheresidualrefractorymaterialsbecomesincreasinglyexpensive,andthepublicisnotconditionedtopayahigherpriceforitsmunicipalwatersupply.Therefractorysubstancesofmostconcernaretheorganiccompounds.Specificstudieshavebeencarriedouttoevaluate2829anddevelop8additionalmethodsfortheirremoval.Themajorunresolvedproblemisthehandlinganddisposalofthetoxicinorganicandorganicsubstancesthatarepresentinthesludges,slurries,and/orresidualconcentratesproducedduringtreatment.Analternativetoextensivetreatmentforurbanuseofnonpotablereclaimedwastewatershasbeentoprovidedualdistributionsystemsoneforthepotablesupplyandaseparateoneforthenonpotablesupply.Althoughfeasibleandinuseinseveralcommunities,8926theAmericanWaterWorksAssociationAWWA,intheforewordtoitsManualonDualSystems,statesthattheuseofadualdistributionsystemis...notarecommendedstandardofpracticebutAJPHAugust1986,Vol.76,No.8960areportofthestateoftheart.8Sincethepublicdrinksonlyabout1percentofthewatersuppliedtothecommunity,andif,asstatedbyLynch,30...whatamountstozeroriskeverbecomesthewillofthepeople,itmightbenecessarytoexchangeourtraditionalonesystemapproachtowaterdistributionforadualsysteminwhichthewaterintendedforhumanconsumptionwouldundergoextremesofmonitoring,testing,andtreatmentandtherestwouldbekeptatlevelsofqualityorsafetythatuntilnowhavebeendeemedtobesatisfactory.Inthetreatmentofreclaimedwastewatersforindirectreuse,acriticalissueisthereliabilityofthetreatmentprocess.Roberts5reportsthatWaterFactory21hasdemonstratedthatpotablewaterqualitystandardscanbesatisfied,forthemostpart,withbetterthan95percentreliabilitybasedonCaliforniacontaminationlevelstandards.Withproperdesignoffacilities,carefuloperation,adequatelytrainedpersonnel,andpossibilityofoccasionalbypassing,mostplantsshouldbeabletoperformaswell.Scientifically,ourabilitytoidentifyandtoquantifythelowlevelsofcontaminantspresentinwaterhasfaroutstrippedourcapabilitiestoevaluateandinterpretthesignificanceofthelevelsmeasuredinassessingpotentialchronichealtheffects.Thereisaneedtodevelopappropriatetestprocedurestodeterminethehealthsignificanceofthemanysubstancescurrentlyidentifiableinwater.Beforereuseofreclaimedwastewatercanbecomeareality,thepublicmustaccepttheproduct.Publicattitudesurveyshaveshownthatalargesegmentofthepublicendorseswastewaterreuseforagriculturalandurbanirrigation,industrialuse,toiletflushing,andsceniclakeswhereasalesserfractionsupportsitsuseforboating/fishing,laundry,andbeachesandbathing,andastillsmallerfractionforfoodcanning,cooking,anddrinking.273133Generalacceptancefordrinkingreclaimedwaterrangedfrom40tomorethan80percent.Ifthereclaimedwaterwastobeofthesameorbetterqualitythanthecurrentsupply,resultsofaDenversurveyshowedthat84.1percentofthepublicagreedtosomedegree.2732Some63percentofDenverresidentsfavoredeventualpotablewaterreuse.27Bruvold33characterizedthemembersofthepublicandtheindividualshavingthemostfavorableattitudetowardreusingreclaimedwastewaterfordrinkingaswellasthosethatdidnothaveafavorableattitude.Inarecentarticle,Wolman34indicatedthatpeopleweremilitant,concerned,fearful,andevenhystericalintheirsearchforguaranteedsafetyandzerorisk.Heidentifiedasaparameterpublicconfrontation,andnotedthatthiscomplexhumanbehavior...compoundedbyconcern,ignorance,misconception,hysteria,andfearoftheunknown...hasitsorigininpressuregroups,officialdom,andthecommunicationsmedia.Thesephenomenaareofhighimport,however,inanyassessmentofthesignificanceofwaterborneillnessesfromwastewaterdischarges.HasthiscomplexhumanbehaviorrelativetothesafetyofourwatersuppliesbeenthemotivatingfactorforthetremendoussurgeintheuseofbottledwaterandbeveragesInconclusion,thedirectreuseofreclaimedwastewatersforpotablepurposesshouldbedeferreduntilenoughscientificevidenceisavailabletoadequatelyassessthepotentiallyadversehealtheffects,bothacuteandchronic.9ThereisaneedforadditionalcomprehensivehealtheffectsstudiesofthetypereportedbyNellor,etal.24WealsoanticipatetheresultsofthelongtermhealtheffectsstudiesplannedbytheCityofDenverasapartofitsdemonstrationprojecttoEDITORIALSevaluatethefeasibilityofreclaimingwastewaterfordirectreuse.35REFERENCES1.FattalB,WaxY,DaviesM,ShuvalHIHealthrisksassociatedwithwastewaterirrigationAnepidemiologicalstudy.AmJPublicHealth198676977979.2.MetzlerDF,CulpRL,StoltenbergHA,WoodwardRL,WaltonG,ChangSL,ClarkeNA,PalmerCM,MiddletonFMEmergencyuseofreclaimedwaterforpotablesupplyatChanute,Kansas.JAmWaterWorksAssoc19585010211057.3.EnglishJN,BennettER,LindstedtKDResearchrequiredtoestablishconfidenceinthepotablereuseofwastewater.JAmWaterWorksAssoc197769131136.4.RobertsPV,McCartyPL,RomanWHDirectinjectionofreclaimedwaterintoanaquifer.JEnvironEngrDiv,AmSocCivilEngrs1978104933949.5.NationalInterimPrimaryDrinkingWaterRegulations1977EPA570/976003.Washington,DCOfficeofWaterSupply,EnvironmentalProtectionAgency.6.FederalRegister19794414042918July18.7.GarrisonWE,MieleRPCurrenttrendsinwaterreclamationtechnology.JAmWaterWorksAssoc197769364369.8.DeBoerJGWastewaterreuseAresourceoranuisanceJAmWaterWorksAssoc198375348356.9.OkunDAReusePanaceaorpieintheskyJAmWaterWorksAssoc19857726.10.AsanoT,WassermanKLGroundwaterrechargeoperationsinCalifornia.JAmWaterWorksAssoc198072380385.11.SontheimerHExperiencewithriverbankfiltrationalongtheRhineRiver.JAmWaterWorksAssoc198072386390.12.PietGJ,ZoetemanBCJOrganicwaterqualitychangesduringsandbankanddunefiltrationofsurfacewatersinTheNetherlands.JAmWaterWorksAssoc198072400404.13.IdelovitchEEnvironmentaleffectsofwaterreusescheme.JEnvironEngrDiv,AmSocCivilEngrs1980106561570.14.IdelovitchE,TerkeltoubR,MichailMTheroleofgroundwaterrechargeinwastewaterreuseIsraelsDanRegionProject,JAmWaterWorksAssoc198072391400.15.Roberts,PVWaterreuseforgroundwaterrechargeAnoverview.JAmWaterWorksAssoc198072375379.16.LarkinEP,TierneyJT,SullivanRPersistenceofvirusonsewageirrigatedvegetables.JEnvironEngrDiv,AmSocCivilEngrs19761022935.17.LarkinEP,TierneyJT,SullivanRPersistenceofvirusonsewageirrigatedvegetables.JEnvironEngrDiv,AmSocCivilEngrs1977103742743.18.CooperRCHealthconsiderationsinuseoftertiaryeffluents.JEnvironEngrDiv,AmSocCivilEngrs19771033747.19.CrookJHealthaspectsofwaterreuseinCalifornia.JEnvironEngrDiv,AmSocCivilEngrs1978104601610.20.ScheuermanPR,BittonG,OvermanAR,GiffordGETransportofvirusesthroughorganicsoilsandsediments.JEnvironEngrDiv,AmSocCivilEngrs1979105629640.21.BixbyRLTransportofvirusesthroughorganicsoilsandsediments.JEnvironEngrDiv,AmSocCivilEngrs1980106654675.22.NealRAEvaluatingpotentialhealthrisksofconsumingreusedwater.JAmWaterWorksAssoc198274638641.23.CrookJWaterreuseinCalifornia.JAmWaterWorksAssoc1985776071.24.NellorMH,BairdRB,SmythJRHealtheffectsofindirectpotablewaterreuse.JAmWaterWorksAssoc1985778896.25.Update.JAmWaterWorksAssoc19857712.26.GallierWTPlanningandimplementingadualdistributionsystem.JAmWaterWorksAssoc1985774044.27.WorkSW,RothbergMR,MillerKJDenverspotablereuseprojectsPathwaystopublicacceptance.JAmWaterWorksAssoc198072435440.28.ReinhardM,DolceCJ,McCartyPL,ArgoDGTraceorganicsremovalbyadvancedwastetreatment.JEnvironEngrDiv,AmSocCivilEngrs1979105675693.29.RandtkeSJ,McCartyPLRemovalofsolublesecondaryeffluentorganics.JEnvironEngrDiv,AmSocCivilEngrs1979105727743.30.LynchWOAperspectiveonthecontroloftoxics.JAmWaterWorksAssoc19847612,14.31.StoneRWaterreclamationTechnologyandpublicacceptance.JEnvironEngrDiv,AmSocCivilEngrs1976102581594.32.MillikenJG,TrumblyASMunicipalrecyclingofwastewater.JAmWaterWorksAssoc197971548555.33.BruvoldWHObtainingpublicsupportforreusewater.3AmWaterWorksAJPHAugust1986,Vol.76,No.8961EDITORIALSAssoc1985777277.34.WolmanAReflections,perceptions,andprojections.JWaterPollControlFed19835514121416.35.LauerWC,RogersSE,RayJMThecurrentstatusofDenverspotablewaterreuseproject.JAmWaterWorksAssoc1985775259.CONRADP.STRAUB,MCE,PHDDr.StraubisnowretiredfromhispostasProfessor,EnvironmentalHealth,UniversityofMinnesotaSchoolofPublicHealth,andiscurrentlyamemberoftheJournalEditorialBoard.AddressreprintrequeststoConradP.Straub,PhD,2330ChaletDrive,ColumbiaHeights,MN55421.C1986AmericanJournalofPublicHealth00900036/861.50CesareanSectionandBreechPresentationsCesareansectionusageintheUnitedStateshasincreaseddramaticallyinthepastfewdecadesfromaround3percentto20percentofallbirths.Reasonscitedincludetheuseofelectronicfetalmonitoring,fearofmalpracticesuits,andfinancialincentives.Anotherveryrealreasonistherecognitionbyphysiciansofthehazardsofvaginaldeliveriestocertaingroupsofbabies.FortneyandcolleaguesintheirpaperelsewhereinthisissueoftheJournalfocusononeofthesehighriskconditionsbreechpresentationandreportonanextraordinarysampleofover10,000suchcasesfromaroundtheworld.Theyfoundthatinhospitalswithlowmortalityratespresumablymoresophisticatedandwithlowerriskpopulations,cesareansectionwasusedforbreechdeliverymuchmorefrequentlythaninhospitalswithhighmortalityrates.Thismightleadsometoconcludethatcesareanisbetterforthesecases,but,astheauthorscorrectlypointout,itisnotthatsimple.Iftheperinatalmortalityishigh,itmaywellmeanahighincidenceoflowbirthweightandverylowbirthweight1000gramsbabies.Theseinfants,inturn,aremorelikelytobewrittenoff,especiallywheregoodintensivecarefornewbornsislacking,andthemothersallowedtodelivervaginallyratherthansquanderpreciousresourcesoncesareansectioninalostcause.Thissinglefactcangofartoexplainthevarianceamongratesandrelativerisksinthethreestrataofhospitals.Obviously,ifcesareansectionisreservedforthebabieswithabettersurvivalchance,itwillmakeforahigherrelativeriskforvaginaldelivery.Evenso,therearesomepointstolearnfromthepaperbyFortney,etal.First,evenwithbreechdeliveries,theworldisfullofhavesandhavenotsi.e.,thetrickledowntheoryinpracticeSecond,given36weeksofgestationalage,particularlyinfootlingpresentationsandinprimiparas,cesareansectionisprobablythesafestrouteofdeliveryforabreech.Fortheverylowbirthweightinfant,thisisnotdemonstrated.Third,thelargebreech3500gramsshouldbedeliveredbycesareansectionwheneverpossible.Fourth,wemustnotforgettheimpactoftheincreasingnumbersofcesareansectionsonmaternalmorbidityandmortality.Andfinally,thephysiciancaringforthesepatientsmustcontinuetoexerciseindividualizedclinicaljudgmentinmakingadecision.Inagivensituation,toparaphrasetheauthors,cesareandeliverydoesnotguaranteeahealthybaby,althoughitenhancestheprobabilityofone.REFERENCE1.FortneyJA,HigginsJE,KennedyKI,LaufeLE,WilkensLDeliverytypeandneonatalmortalityamong10,749breeches.AmJPublicHealth198676980985.GEORGEM.RYAN,JR.,MDAddressreprintrequeststoGeorgeM.Ryan,Jr.,MD,ProfessorofObstetricsandGynecology,UniversityofTennessee,CenterfortheHealthSciences,800MadisonAvenue,Memphis,TN38163.C1986AmericanJournalofPublicHealth00900036/861.50962AJPHAugust1986,Vol.76,No.8
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