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In this study, we assessed a harmonized binational dataset for the effects of extreme precipitation events (\u226590th percentile) and preceding dry periods, source water turbidity, total coliforms, and protozoan AGIs \u2013 cryptosporidiosis and giardiasis \u2013 in the populations served by four DWSs that source surface water from Lake Ontario (Hamilton and Toronto, Ontario, Canada) and Lake Michigan (Green Bay and Milwaukee, Wisconsin, USA) from January 2009 through August 2014. We used distributed lag non-linear Poisson regression models adjusted for seasonality and found extreme precipitation weeks preceded by dry periods increased the relative risk of protozoan AGI after 1 and 3\u20135 weeks in three of the four cities, although only statistically significant in two. Our results suggest that the risk of protozoan AGI increases with extreme precipitation preceded by a dry period. As extreme precipitation patterns become more frequent with climate change, the ability to detect changes in water quality and effectively treat source water of varying quality is increasingly important for adaptive capacity and protection of public health.<\/jats:p>","DOI":"10.2166\/wh.2022.018","type":"journal-article","created":{"date-parts":[[2022,4,27]],"date-time":"2022-04-27T00:33:41Z","timestamp":1651019621000},"page":"849-862","update-policy":"https:\/\/doi.org\/10.2166\/iwapcrossmarkpolicypage","source":"Crossref","is-referenced-by-count":15,"title":["Associations between extreme precipitation, drinking water, and protozoan acute gastrointestinal illnesses in four North American Great Lakes cities (2009\u20132014)"],"prefix":"10.2166","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8598-0989","authenticated-orcid":false,"given":"Ryan C.","family":"Graydon","sequence":"first","affiliation":[{"name":"a International Joint Commission: Great Lakes Regional 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