Health effects of beach water pollution in Hong Kong

Regional public health cost estimates of contaminated coastal waters: a case study of gastroenteritis at southern California beaches

We present estimates of annual public health impacts, both illnesses and cost of illness, attributable to excess gastrointestinal illnesses caused by swimming in contaminated coastal waters at beaches in southern California. Beach-specific enterococci densities are used as inputs to two epidemiological dose-response models to predict the risk of gastrointestinal illness at 28 beaches spanning 160 km of coastline in Los Angeles and Orange Counties. We use attendance data along with the health cost of gastrointestinal illness to estimate the number of illnesses among swimmers and their likely economic impact. We estimate that between 627,800 and 1,479,200 excess gastrointestinal illnesses occur at beaches in Los Angeles and Orange Counties each year. Using a conservative health cost of gastroenteritis, this corresponds to an annual economic loss of dollars 21 or dollars 51 million depending upon the underlying epidemiological model used (in year 2000 dollars). Results demonstrate that improving coastal water quality could result in a reduction of gastrointestinal illnesses locally and a concurrent savings in expenditures on related health care costs.

A randomized controlled trial assessing infectious disease risks from bathing in fresh recreational waters in relation to the concentration of Escherichia coli, intestinal enterococci, Clostridium perfringens, and somatic coliphages

We performed epidemiologic studies at public freshwater bathing sites in Germany to provide a better scientific basis for the definition of recreational water quality standards. A total of 2,196 participants were recruited from the local population and randomized into bathers and nonbathers. Bathers were exposed for 10 min and had to immerse their head at least three times. Water samples for microbiological analysis were collected at 20-min intervals. Unbiased concentration-response effects with no-observed-adverse-effect levels (NOAELs) were demonstrated for three different definitions of gastroenteritis and four fecal indicator organisms. Relative risks for bathing in waters with levels above NOAELs compared with nonbathing ranged from 1.8 (95% CI, 1.2-2.6) to 4.6 (95% CI, 2.1-10.1), depending on the definition of gastroenteritis. The effect of swallowing water provided additional evidence for true dose-response relationships. Based on the NOAELs, the following guide values for water quality are suggested: 100 Escherichia coli, 25 intestinal enterococci, 10 somatic coliphages, or 10 Clostridium perfringens per 100 mL. Recreational water quality standards are intended to protect the health of those consumers who are not already immune or resistant to pathogens that may be associated with indicator organisms. In contrast to current World Health Organization recommendations, we concluded that standards should be based on rates of compliance with NOAELs rather than on attributable risks determined above NOAELs, because these risks depend mainly on the unpredictable susceptibility of the cohorts. Although in theory there is no threshold in real concentration-response relationships, we demonstrated that a NOAEL approach would be a more robust and practical solution to the complex problem of setting standards.

Real-time PCR quantification of human adenoviruses in urban rivers indicates genome prevalence but low infectivity

Real-time PCR was applied to quantify the abundance of human adenoviruses in two southern California urban rivers, the San Gabriel and Los Angeles. A total of 114 river samples from five different locations were collected over a 1-year period and analyzed for human adenoviruses, along with fecal indicator bacteria and coliphages. Adenoviruses were detected by real-time PCR in approximately 16% of the samples, with concentrations ranging from 10(2) to 10(4) genomes per liter. However, a plaque assay using two human tissue culture cell lines, HEK-293A and A549, yielded negative results, suggesting that adenoviruses detected by real-time PCR are likely noninfectious. Enterovirus genome was detected in approximately 7% of the samples by reverse transcription-PCR. Analysis by Spearman's rho rank order correlation showed significant correlations between fecal indicator bacteria and indicator virus (total coliform, fecal coliform, enterococcus, and coliphage values). However, no significant correlations were found between human adenoviruses quantified by real-time PCR and culturable coliphages or fecal indicator bacteria. Kruskal-Wallis chi-square analysis showed significant seasonal variability of all fecal indicator bacteria and coliphages, while no significant variability was observed for adenoviruses or enteroviruses. This study presents the first quantitative measurement of human adenovirus genomes in urban rivers and their statistical relationship to fecal indicator bacteria and coliphages. The uncoupling between high-number genome copies of adenoviruses detected by real-time PCR and the absence of infectivity detected by tissue culture suggests that genome-based detection methods are inadequate for direct assessment of human health risk.

The influence of rainfall on the incidence of microbial faecal indicators and the dominant sources of faecal pollution in a Florida river

AIMS

An assessment of microbial densities in an urbanized Florida watershed was performed during a period of changing rainfall patterns to investigate the role of climate coupled with urbanization in declining water quality.

METHODS AND RESULTS

Concentrations of traditional and alternative faecal indicators were assessed by standard methods over 24 months. Sources of faecal contamination were determined by antibiotic resistance analysis (ARA) of faecal coliform (FC) bacteria. Composite indices of indicator organisms based on a suite of microbial measurements were used to quantify pollution impacts in the river. ARA results found that FC from wild animal sources dominated during the drought, and the relative frequency of FC from human sources increased after cumulative rainfall increased to near-normal levels.

CONCLUSIONS

Changes observed in faecal indicator densities and in FC sources during changing rainfall patterns strongly suggest a role of precipitation on the sources and extent of microbial pollution in urbanized coastal watersheds.

SIGNIFICANCE AND IMPACT OF THE STUDY

Bacterial source tracking coupled with a composite index of microbial contamination resulted in a more complete picture of microbial pollution within the river, as opposed to the general practice of reliance on one indicator organism. Improved land use decisions in urban areas are necessary to insure maintenance of coastal environmental health under changing climate patterns and population density.

Ear problems in swimmers

Acute diffuse otitis externa (swimmer's ear), otomycosis, exostoses, traumatic eardrum perforation, middle ear infection, and barotraumas of the inner ear are common problems in swimmers and people engaged in aqua activities. The most common ear problem in swimmers is acute diffuse otitis externa, with Pseudomonas aeruginosa being the most common pathogen. The symptoms are itching, otalgia, otorrhea, and conductive hearing loss. The treatment includes frequent cleansing of the ear canal, pain control, oral or topical medications, acidification of the ear canal, and control of predisposing factors. Swimming in polluted waters and ear-canal cleaning with cotton-tip applicators should be avoided. Exostoses are usually seen in people who swim in cold water and present with symptoms of accumulated debris, otorrhea and conductive hearing loss. The treatment for exostoses is transmeatal surgical removal of the tumors. Traumatic eardrum perforations may occur during water skiing or scuba diving and present with symptoms of hearing loss, otalgia, otorrhea, tinnitus and vertigo. Tympanoplasty might be needed if the perforations do not heal spontaneously. Patients with chronic otitis media with active drainage should avoid swimming, while patients who have undergone mastoidectomy and who have no cavity problems may swim. For children with ventilation tubes, surface swimming is safe in a clean, chlorinated swimming pool. Sudden sensorineural hearing loss and some degree of vertigo may occur after diving because of rupture of the round or oval window membrane.

Bacteriological examination of ballast water in Singapore Harbour by flow cytometry with FISH

In this study the concentrations of total bacteria, enterobacteria, Vibrio spp., and E. coli have been compared for ballast water samples taken from ships in Singapore Harbour. The cell concentrations were enumerated using FISH and flow cytometry. The data were highly variable, reflecting the many influences upon ballast water as it is utilized in the shipping industry. The concentration of bacterial species was determined as a proportion of the total concentration of cells for the ballast water sampled. For the ballast water sampled these concentrations were 0.67-39.55% for eubacteria, 0-2.46% for enterobacteria, 0.18-35.82% for Vibrio spp., and 0-2.46% for E. coli. Using FISH and flow cytometry, an informative determination of the bacterial hazards of ship ballast water can be made.

Risks Associated with the Microbiological Quality of Bodies of Fresh and Marine Water Used for Recreational Purposes: Summary Estimates Based on Published Epidemiological Studies

The current European standards for microbiological quality of bathing water (i.e., all running or still fresh waters or parts thereof and/or sea water [with the exception of water intended for therapeutic purposes and water used in swimming pools]) were issued in 1976 and are currently undergoing revision. In this article, the authors propose parameters for select microorganism indicators to assist in the establishment of public-health-based objectives for fresh and marine water quality. A type-II meta-analysis of the results of 18 published epidemiological studies was implemented in an attempt to characterize the relationship(s) between concentrations of bacterial indicators and rates of acute gastrointestinal diseases among bathers who had used fresh or marine water for recreational purposes. The authors fit multiple linear-regression models, which allowed for random effects across studies, to derive dose-response curves. Several confounders and effect modifiers were controlled for in the analyses. Risks were then estimated for a hypothetical individual who would bathe 20 times/yr in water that contained a given concentration of microorganisms. For fresh-water-associated highly credible gastrointestinal illnesses, a level of 10 fecal coliforms/100 ml water yielded an attributable risk of 0.2 cases/1,000 person-years; a risk of 2 cases/1,000 person-years was found for fecal streptococci. The corresponding yearly attributable risks were 1 and 13 cases/1,000 person-years, respectively, for 100 bacteria/100 ml fresh water. Risks associated with fecal coliforms were found to be lower in marine water than in fresh water. Irrespective of the type of water examined, total coliforms were related only weakly with acute digestive morbidity. Developers of future bathing-water standards should state the level of risk deemed acceptable for public health. The authors of this study maintain that levels of fecal coliforms and fecal streptococci should be used as criteria for infectious risk management associated with bodies of marine and fresh water used for recreational purposes.

Do U.S. Environmental Protection Agency water quality guidelines for recreational waters prevent gastrointestinal illness? A systematic review and meta-analysis

Despite numerous studies, uncertainty remains about how water quality indicators can best be used in the regulation of recreational water. We conducted a systematic review of this topic with the goal of quantifying the association between microbial indicators of recreational water quality and gastrointestinal (GI) illness. A secondary goal was to evaluate the potential for GI illness below current guidelines. We screened 976 potentially relevant studies and from these identified 27 studies. From the latter, we determined summary relative risks for GI illness in relation to water quality indicator density. Our results support the use of enterococci in marine water at U.S. Environmental Protection Agency guideline levels. In fresh water, (Italic)Escherichia(/Italic) coli was a more consistent predictor of GI illness than are enterococci and other bacterial indicators. A log (base 10) unit increase in enterococci was associated with a 1.34 [95% confidence intervals (CI), 1.00-1.75] increase in relative risk in marine waters, and a log (base 10) unit increase in E. coli was associated with a 2.12 (95% CI, 0.925-4.85) increase in relative risk in fresh water. Indicators of viral contamination were strong predictors of GI illness in both fresh and marine environments. Significant heterogeneity was noted among the studies. In our analysis of heterogeneity, studies that used a nonswimming control group, studies that focused on children, and studies of athletic or other recreational events found elevated relative risks. Future studies should focus on the ability of new, more rapid and specific microbial methods to predict health effects, and estimating the risks of recreational water exposure among susceptible persons.

Pathogenic human viruses in coastal waters

This review addresses both historical and recent investigations into viral contamination of marine waters. With the relatively recent emergence of molecular biology-based assays, a number of investigations have shown that pathogenic viruses are prevalent in marine waters being impacted by sewage. Research has shown that this group of fecal-oral viral pathogens (enteroviruses, hepatitis A viruses, Norwalk viruses, reoviruses, adenoviruses, rotaviruses, etc.) can cause a broad range of asymptomatic to severe gastrointestinal, respiratory, and eye, nose, ear, and skin infections in people exposed through recreational use of the water. The viruses and the nucleic acid signature survive for an extended period in the marine environment. One of the primary concerns of public health officials is the relationship between the presence of pathogens and the recreational risk to human health in polluted marine environments. While a number of studies have attempted to address this issue, the relationship is still poorly understood. A contributing factor to our lack of progress in the field has been the lack of sensitive methods to detect the broad range of both bacterial and viral pathogens. The application of new and advanced molecular methods will continue to contribute to our current state of knowledge in this emerging and important field.

Marine swimming-related illness: implications for monitoring and environmental policy

There is increasing evidence that environmental degradation may be contributing to an increase in marine-related diseases across a wide range of taxonomic groups. This includes a growing number of reports of both recreational and occupational users of marine waters developing gastrointestinal, respiratory, dermatologic, and ear, nose, and throat infections. The duration and type of exposure, concentration of pathogens, and host immunity determine the risk of infection. Public health authorities may not be able to accurately predict the risk of waterborne disease from marine waters due to the limitations of conventional monitoring, as well as erroneous perceptions of pathogen life span in marine systems. Pathogens undetectable by conventional methods may remain viable in marine waters, and both plankton and marine sediments may serve as reservoirs for pathogenic organisms, which can emerge to become infective when conditions are favorable. In this paper we address the environmental factors that may contribute to illness, the types of associated economic costs, the issues of water quality monitoring and the policy implications raised by the apparent rise in incidence of marine water-related illnesses.

Recreation in coastal waters: health risks associated with bathing in sea water

STUDY OBJECTIVE

To find out whether bathing in sewage polluted waters implies a danger to bathers' health and to determine the best microbiological indicator to predict the relation between bathing and the appearance of some symptoms.

DESIGN

Cohort study.

SETTING

City of Santander (north of Spain).

PARTICIPANTS

From the people going to four Santander beaches in the period from 1 July to 16 September 1998, a cohort of 2774 persons was recruited who agreed to participate in this study. Of those, 1858 successfully completed a follow up interview conducted in seven days. Respiratory, gastrointestinal, eye, and ear symptoms, and fever occurring during the seven day follow up were recorded.

MAIN RESULTS

A total of 136 participants (7.5%) reported symptoms. Visitors reported experiencing symptoms with more frequency than residents. Incidence rates of gastrointestinal, cutaneous and high respiratory tract symptoms were higher in bathers, but the differences were not significant. Total symptoms were related with the amount of total coliforms, faecal coliforms, and faecal streptococci in the water. Gastrointestinal and skin symptoms kept a positive trend with the degree of water pollution by total coliforms in both crude and adjusted analyses. An increased risk was observed in 2500-9999 total coliforms per 100 ml, a figure over the proposed standard, although below the European Union mandatory limit.

CONCLUSIONS

The results of this study suggest that total coliforms are the best predictors of the symptoms.

Generation of enterococci bacteria in a coastal saltwater marsh and its impact on surf zone water quality

Elevated levels of enterococci bacteria, an indicator of fecal pollution, are routinely detected in the surf zone at Huntington State and City Beaches in southern California. A multidisciplinary study was carried out to identify sources of enterococci bacteria landward of the coastline. We find that enterococci bacteria are present at high concentrations in urban runoff, bird feces, marsh sediments, and on marine vegetation. Surprisingly, urban runoff appears to have relatively little impact on surf zone water quality because of the long time required for this water to travel from its source to the ocean. On the other hand, enterococci bacteria generated in a tidal saltwater marsh located near the beach significantly impact surf zone water quality. This study identifies a potential tradeoff between restoring coastal wetlands and protecting beach water quality and calls into question the use of ocean bathing water standards based on enterococci at locations near coastal wetlands.

A clustering of Crohn's disease in Mankato, Minnesota

Infrequently, clusterings of Crohn's disease (CD) occur that suggest it is transmissible. We studied such a clustering. Graduates of the Mankato West High School Class of 1980 were contacted by mail and asked to respond, by self-addressed postcard, to a six-item questionnaire about inflammatory bowel disease and CD. Responses were followed-up by telephone contact and additional mailings. Two visits were made to Mankato, Minnesota, to interview individuals with CD, to obtain medical records, radiographs, and sera, and to study environmental risk factors. Of the 320 graduates of the class of 1980, 285 were contacted. Seven cases of CD were identified, the equivalent of a prevalence of 2,400/100,000. Concerns were discovered that CD may have emanated from recreational swimming. Fecal coliform counts in excess of 200/dL, the standard above which water is regarded as unsafe for recreational use, had been recorded year after year for the Blue Earth River at Mankato and for the Minnesota River. Recent fecal coliform counts (1993-1995) of Lake Washington, Lake German/Jefferson, and Lake Shetek were greater than 200/dL in 57%, 65%, and 62% of water samples. This clustering, in unrelated individuals, argues against a genetic cause for CD and suggests that environmental transmission occurred.

Detection of viral pathogens by reverse transcriptase PCR and of microbial indicators by standard methods in the canals of the Florida Keys

In order to assess the microbial water quality in canal waters throughout the Florida Keys, a survey was conducted to determine the concentration of microbial fecal indicators and the presence of human pathogenic microorganisms. A total of 19 sites, including 17 canal sites and 2 nearshore water sites, were assayed for total coliforms, fecal coliforms, Escherichia coli, Clostridium perfringens, enterococci, coliphages, F-specific (F(+)) RNA coliphages, Giardia lamblia, Cryptosporidium parvum, and human enteric viruses (polioviruses, coxsackie A and B viruses, echoviruses, hepatitis A viruses, Norwalk viruses, and small round-structured viruses). Numbers of coliforms ranged from <1 to 1, 410, E. coli organisms from <1 to 130, Clostridium spp. from <1 to 520, and enterococci from <1 to 800 CFU/100 ml of sample. Two sites were positive for coliphages, but no F(+) phages were identified. The sites were ranked according to microbial water quality and compared to various water quality standards and guidelines. Seventy-nine percent of the sites were positive for the presence of enteroviruses by reverse transcriptase PCR (polioviruses, coxsackie A and B viruses, and echoviruses). Sixty-three percent of the sites were positive for the presence of hepatitis A viruses. Ten percent of the sites were positive for the presence of Norwalk viruses. Ninety-five percent of the sites were positive for at least one of the virus groups. These results indicate that the canals and nearshore waters throughout the Florida Keys are being impacted by human fecal material carrying human enteric viruses through current wastewater treatment strategies such as septic tanks. Exposure to canal waters through recreation and work may be contributing to human health risks.

Faecal pollution of ocean swimming pools and stormwater outlets in eastern Sydney

We determined the levels of faecal contamination over a three-year period from 1991 to 1993 at selected ocean swimming pools and stormwater outlets to assess whether these levels represented a threat to public health. Three popular ocean swimming pools and three nearby stormwater outlets located in Sydney's eastern suburbs were included in the analysis. The ocean swimming pools consistently had elevated levels of faecal coliform bacteria; the highest microbe levels were observed in a pool used largely by children. Faecal coliform bacteria counts in the ocean pools at times reach levels likely to be associated with illness in bathers. Stormwater outlets at three locations had reducing counts over the three-year period. An improved system of sampling, testing and risk communication appears to be needed to reduce potential health risks to users of these popular ocean pools.

Marine waters contaminated with domestic sewage: nonenteric illnesses associated with bather exposure in the United Kingdom

OBJECTIVES

This study identified possible dose-response relationships among bathers exposed to marine waters contaminated with domestic sewage and subsequent risk of nonenteric illness.

METHODS

Four intervention follow-up studies were conducted within the United Kingdom. Healthy volunteers (n = 1273) were randomized into bather and nonbather groups. Intensive water-quality monitoring was used to assign five bacteriological indices of water quality to individual bathers. Illnesses studied were acute febrile respiratory illness, and eye, ear, and skin ailments.

RESULTS

Fecal streptococci exposure was predictive of acute febrile respiratory illness, while fecal coliform exposure was predictive of ear ailments. Estimated thresholds of effect occurred at bather exposures above 60 fecal streptococci and 100 fecal coliform per 100 ml of water, respectively. Although no relationship was found between eye ailments and indicator organism exposure, compared with nonbathers, bathers were at higher risk for eye ailments.

CONCLUSIONS

Nonenteric illness can be transmitted via recreational contact with marine waters contaminated with sewage. These results argue against the use of a single indicator to establish water quality standards.

Risk of otitis externa after swimming in recreational fresh water lakes containing Pseudomonas aeruginosa

OBJECTIVE

To determine whether an outbreak of otitis externa was due to bathing in recreational fresh water lakes and to establish whether the outbreak was caused by Pseudomonas aeruginosa in the water.

DESIGN

Matched case-control study.

SETTING

The Achterhoek area, the Netherlands.

SUBJECTS

98 cases with otitis externa and 149 controls matched for age, sex, and place of residence.

MAIN OUTCOME MEASURES

Odds ratios for type of swimming water and frequency of swimming; presence of P aeruginosa in ear swabs and fresh water lakes.

RESULTS

Otitis externa was strongly associated with swimming in recreational fresh water lakes in the previous two weeks (odds ratio 15.5 (95% confidence interval) 4.9 to 49.2) compared with non-swimming). The risk increased with the number of days of swimming, and subjects with recurrent ear disease had a greatly increased risk. The lakes met the Dutch bathing water standards and those set by the European Commission for faecal pollution in the summer of 1994, but P aeruginosa was isolated from all of them, as well as from the ear swabs of 78 (83%) of the cases and 3 (4%) of the controls.

CONCLUSIONS

Even when current bathing water standards are met, swimming can be associated with a substantial risk of otitis externa because of exposure to P aeruginosa. People with recurrent ear disease should take special care when swimming in waters containing P aeruginosa.

Methods for enumerating Escherichia coli in subtropical waters

The standard membrane filtration method of the UK has been modified in order to improve its specificity for enumerating Escherichia coli in the subtropical waters of Hong Kong. This involves incorporating into the membrane lauryl sulphate (mLS) method either an in situ urease test (the mLS-UA method), or an in situ beta-glucuronidase test (the mLS-GUD method). The false-positive errors of the mLS-UA and mLS-GUD methods are low, ranging from 3-5%. A comparison between the membrane filtration (mLS-UA) method and the multiple tube technique in testing E. coli in subtropical beach-waters has demonstrated that the former can give much more precise counts, and is the method of choice for such a purpose. The mLS-GUD method, for which automated counting of E. coli colonies is possible, is a good alternative to mLS-UA in routine enumeration of this bacterial indicator in environmental waters.

Variations in microbial indicator densities in beach waters and health-related assessment of bathing water quality

Daily and hourly variations in microbial indicators densities in the beach-waters of Hong Kong have been described. The levels of Escherichia coli at a number of beaches was observed to be influenced by tide, and for staphylococci, by bather numbers. The tidal influence was most obvious during spring tides; and for the effect of bathers, during neap tides. Both organisms are present in high densities in external sources of faecal pollution of bathing beaches, with the average staphylococci to E. coli ratios being 0.04-3. Staphylococci may serve as an indicator of bather density and the risk of cross-infection amongst bathers (rather than as another indicator of faecal contamination) when the average staphylococci to E. coli ratio for a bathing beach is considerably higher than 3. The variability of microbial indicator densities means the routine sampling of bathing beaches should be carried out on weekend days with maximum numbers of swimmers exposed to the water, and spread throughout the bathing season.