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While serious violations like those in the Flint, Michigan, crisis are rare, ensuring reliable access to safe drinking water poses challenges for communities across the country. Researchers found that between 1982 and 2015, 9 million to 45 million people annually were affected by water quality issues, and that low-income, rural regions were most vulnerable. Infractions were more numerous in "hot spots" in Texas, Oklahoma and Idaho, suggesting that these systems struggle with recurring problems. For this first nationwide assessment of drinking water quality over several decades, trends in health-related incidents were evaluated along with vulnerability factors possibly influencing the frequency of violations since the 1974 passage of the Safe Drinking Water Act. Not all infractions pose immediate health concerns, but drinking water contaminants can cause short-term illnesses such as gastroenteritis, as well as chronic conditions including cancer and neurological disorders.