Roof-harvested rainwater (RHRW) has been considered an effective alternative water source for drinking and various nonpotable uses in a number of countries throughout the world. The most significant issue in relation to using untreated RHRW for drinking or other potable uses, however, is the potential public health risks associated with microbial pathogens. This paper reviews the available research reporting on the microbial quality of RHRW and provides insight on the capacity of fecal indicator bacteria to monitor health risks and disease outbreaks associated with the consumption of untreated RHRW. Several zoonotic bacterial and protozoan pathogens were detected in individual and communal rainwater systems. The majority of the studies reported in the literature assessed the quality of rainwater on the basis of the presence or absence of specific pathogens, with little information available regarding the actual numbers of such pathogens. In addition, no information is available concerning the ongoing prevalence of different pathogens in RHRW over time. The published data suggest that the microbial quality of RHRW should be considered less than that expected for potable water and that the commonly used indicators may not be suitable to indicate the presence of pathogens in RHRW. Several case control studies established potential links between gastroenteritis and consumption of untreated RHRW. Therefore, health risks assessment models, such as those using Quantitative Microbial Risk Assessment, should be used to manage and mitigate health risks associated with drinking and nonpotable uses of RHRW.