An in-premise model for Legionella exposure during showering events

Applications of Quantitative Microbial Risk Assessment to Respiratory Pathogens and Implications for Uptake in Policy: A State-of-the-Science Review

BACKGROUND

Respiratory tract infections are major contributors to the global disease burden. Quantitative microbial risk assessment (QMRA) holds potential as a rapidly deployable framework to understand respiratory pathogen transmission and inform policy on infection control.

OBJECTIVES

The goal of this paper was to evaluate, motivate, and inform further development of the use of QMRA as a rapid tool to understand the transmission of respiratory pathogens and improve the evidence base for infection control policies.

METHODS

We conducted a literature review to identify peer-reviewed studies of complete QMRA frameworks on aerosol inhalation or contact transmission of respiratory pathogens. From each of the identified studies, we extracted and summarized information on the applied exposure model approaches, dose-response models, and parameter values, including risk characterization. Finally, we reviewed linkages between model outcomes and policy.

RESULTS

We identified 93 studies conducted in 16 different countries with complete QMRA frameworks for diverse respiratory pathogens, including SARS-CoV-2, Legionella spp., Staphylococcus aureus, influenza, and Bacillus anthracis. Six distinct exposure models were identified across diverse and complex transmission pathways. In 57 studies, exposure model frameworks were informed by their ability to model the efficacy of potential interventions. Among interventions, masking, ventilation, social distancing, and other environmental source controls were commonly assessed. Pathogen concentration, aerosol concentration, and partitioning coefficient were influential exposure parameters as identified by sensitivity analysis. Most (84%, n = 78 ) studies presented policy-relevant content including a) determining disease burden to call for policy intervention, b) determining risk-based threshold values for regulations, c) informing intervention and control strategies, and d) making recommendations and suggestions for QMRA application in policy.

CONCLUSIONS

We identified needs to further the development of QMRA frameworks for respiratory pathogens that prioritize appropriate aerosol exposure modeling approaches, consider trade-offs between model validity and complexity, and incorporate research that strengthens confidence in QMRA results. https://doi.org/10.1289/EHP12695.

Modelling dynamics between free-living amoebae and bacteria

Free-living amoebae (FLA) serve as hosts for a variety of endosymbionts, which are microorganisms that reside and multiply within the FLA. Some of these endosymbionts pose a pathogenic threat to humans, animals, or both. The symbiotic relationship with FLA not only offers these microorganisms protection but also enhances their survival outside their hosts and assists in their dispersal across diverse habitats, thereby escalating disease transmission. This review is intended to offer an exhaustive overview of the existing mathematical models that have been applied to understand the dynamics of FLA, especially concerning their interactions with bacteria. An extensive literature review was conducted across Google Scholar, PubMed, and Scopus databases to identify mathematical models that describe the dynamics of interactions between FLA and bacteria, as published in peer-reviewed scientific journals. The literature search revealed several FLA-bacteria model systems, including Pseudomonas aeruginosa, Pasteurella multocida, and Legionella spp. Although the published mathematical models account for significant system dynamics such as predator-prey relationships and non-linear growth rates, they generally overlook spatial and temporal heterogeneity in environmental conditions, such as temperature, and population diversity. Future mathematical models will need to incorporate these factors to enhance our understanding of FLA-bacteria dynamics and to provide valuable insights for future risk assessment and disease control measures.

Opportunistic Pathogens in Drinking Water Distribution Systems-A Review

In contrast to "frank" pathogens, like Salmonella entrocolitica, Shigella dysenteriae, and Vibrio cholerae, that always have a probability of disease, "opportunistic" pathogens are organisms that cause an infectious disease in a host with a weakened immune system and rarely in a healthy host. Historically, drinking water treatment has focused on control of frank pathogens, particularly those from human or animal sources (like Giardia lamblia, Cryptosporidium parvum, or Hepatitis A virus), but in recent years outbreaks from drinking water have increasingly been due to opportunistic pathogens. Characteristics of opportunistic pathogens that make them problematic for water treatment include: (1) they are normally present in aquatic environments, (2) they grow in biofilms that protect the bacteria from disinfectants, and (3) under appropriate conditions in drinking water systems (e.g., warm water, stagnation, low disinfectant levels, etc.), these bacteria can amplify to levels that can pose a public health risk. The three most common opportunistic pathogens in drinking water systems are Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa. This report focuses on these organisms to provide information on their public health risk, occurrence in drinking water systems, susceptibility to various disinfectants, and other operational practices (like flushing and cleaning of pipes and storage tanks). In addition, information is provided on a group of nine other opportunistic pathogens that are less commonly found in drinking water systems, including Aeromonas hydrophila, Klebsiella pneumoniae, Serratia marcescens, Burkholderia pseudomallei, Acinetobacter baumannii, Stenotrophomonas maltophilia, Arcobacter butzleri, and several free-living amoebae including Naegleria fowleri and species of Acanthamoeba. The public health risk for these microbes in drinking water is still unclear, but in most cases, efforts to manage Legionella, mycobacteria, and Pseudomonas risks will also be effective for these other opportunistic pathogens. The approach to managing opportunistic pathogens in drinking water supplies focuses on controlling the growth of these organisms. Many of these microbes are normal inhabitants in biofilms in water, so the attention is less on eliminating these organisms from entering the system and more on managing their occurrence and concentrations in the pipe network. With anticipated warming trends associated with climate change, the factors that drive the growth of opportunistic pathogens in drinking water systems will likely increase. It is important, therefore, to evaluate treatment barriers and management activities for control of opportunistic pathogen risks. Controls for primary treatment, particularly for turbidity management and disinfection, should be reviewed to ensure adequacy for opportunistic pathogen control. However, the major focus for the utility's opportunistic pathogen risk reduction plan is the management of biological activity and biofilms in the distribution system. Factors that influence the growth of microbes (primarily in biofilms) in the distribution system include, temperature, disinfectant type and concentration, nutrient levels (measured as AOC or BDOC), stagnation, flushing of pipes and cleaning of storage tank sediments, and corrosion control. Pressure management and distribution system integrity are also important to the microbial quality of water but are related more to the intrusion of contaminants into the distribution system rather than directly related to microbial growth. Summarizing the identified risk from drinking water, the availability and quality of disinfection data for treatment, and guidelines or standards for control showed that adequate information is best available for management of L. pneumophila. For L. pneumophila, the risk for this organism has been clearly established from drinking water, cases have increased worldwide, and it is one of the most identified causes of drinking water outbreaks. Water management best practices (e.g., maintenance of a disinfectant residual throughout the distribution system, flushing and cleaning of sediments in pipelines and storage tanks, among others) have been shown to be effective for control of L. pneumophila in water supplies. In addition, there are well documented management guidelines available for the control of the organism in drinking water distribution systems. By comparison, management of risks for Mycobacteria from water are less clear than for L. pneumophila. Treatment of M. avium is difficult due to its resistance to disinfection, the tendency to form clumps, and attachment to surfaces in biofilms. Additionally, there are no guidelines for management of M. avium in drinking water, and one risk assessment study suggested a low risk of infection. The role of tap water in the transmission of the other opportunistic pathogens is less clear and, in many cases, actions to manage L. pneumophila (e.g., maintenance of a disinfectant residual, flushing, cleaning of storage tanks, etc.) will also be beneficial in helping to manage these organisms as well.

Quantitative Microbial Risk Assessment Framework Incorporating Water Ages with Legionella pneumophila Growth Rates

Water age in drinking water systems is often used as a proxy for water quality but is rarely used as a direct input in assessing microbial risk. This study directly linked water ages in a premise plumbing system to concentrations of Legionella pneumophila via a growth model. In turn, the L. pneumophila concentrations were used for a quantitative microbial risk assessment to calculate the associated probabilities of infection (Pinf) and clinically severe illness (Pcsi) due to showering. Risk reductions achieved by purging devices, which reduce water age, were also quantified. The median annual Pinf exceeded the commonly used 1 in 10,000 (10-4) risk benchmark in all scenarios, but the median annual Pcsi was always 1-3 orders of magnitude below 10-4. The median annual Pcsi was lower in homes with two occupants (4.7 × 10-7) than with one occupant (7.5 × 10-7) due to more frequent use of water fixtures, which reduced water ages. The median annual Pcsi for homes with one occupant was reduced by 39-43% with scheduled purging 1-2 times per day. Smart purging devices, which purge only after a certain period of nonuse, maintained these lower annual Pcsi values while reducing additional water consumption by 45-62%.

On-site filtration of large sample volumes improves the detection of opportunistic pathogens in drinking water distribution systems

In this study, we compared conventional vacuum filtration of small volumes through disc membranes (effective sample volumes for potable water: 0.3-1.0 L) with filtration of high volumes using ultrafiltration (UF) modules (effective sample volumes for potable water: 10.6-84.5 L) for collecting bacterial biomass from raw, finished, and tap water at seven drinking water systems. Total bacteria, Legionella spp., Legionella pneumophila, Mycobacterium spp., and Mycobacterium avium complex in these samples were enumerated using both conventional quantitative PCR (qPCR) and viability qPCR (using propidium monoazide). In addition, PCR-amplified gene fragments were sequenced for microbial community analysis. The frequency of detection (FOD) of Legionella spp. in finished and tap water samples was much greater using UF modules (83% and 77%, respectively) than disc filters (24% and 33%, respectively). The FODs for Mycobacterium spp. in raw, finished, and tap water samples were also consistently greater using UF modules than disc filters. Furthermore, the number of observed operational taxonomic units and diversity index values for finished and tap water samples were often substantially greater when using UF modules as compared to disc filters. Conventional and viability qPCR yielded similar results, suggesting that membrane-compromised cells represented a minor fraction of total bacterial biomass. In conclusion, our research demonstrates that large-volume filtration using UF modules improved the detection of opportunistic pathogens at the low concentrations typically found in public drinking water systems and that the majority of bacteria in these systems appear to be viable in spite of disinfection with free chlorine and/or chloramine.IMPORTANCEOpportunistic pathogens, such as Legionella pneumophila, are a growing public health concern. In this study, we compared sample collection and enumeration methods on raw, finished, and tap water at seven water systems throughout the State of Minnesota, USA. The results showed that on-site filtration of large water volumes (i.e., 500-1,000 L) using ultrafiltration membrane modules improved the frequency of detection of relatively rare organisms, including opportunistic pathogens, compared to the common approach of filtering about 1 L using disc membranes. Furthermore, results from viability quantitative PCR (qPCR) with propidium monoazide were similar to conventional qPCR, suggesting that membrane-compromised cells represent an insignificant fraction of microorganisms. Results from these ultrafiltration membrane modules should lead to a better understanding of the microbial ecology of drinking water distribution systems and their potential to inoculate premise plumbing systems with opportunistic pathogens where conditions are more favorable for their growth.

Impact of fixture purging on water age and excess water usage, considering stochastic water demands

Higher water ages are linked with water quality decline as chlorine dissipates, temperatures become more favorable for microbial growth, and metals and organic matter leach from the pipes. Water fixtures with automated purging devices can limit water age in premise plumbing systems, but also increase water use. To develop purging strategies that lower age while also minimizing water use, the stochastic nature of water demands must be considered. In this research, a hydraulic plumbing network model, with stochastic demands at fixtures, was used to compare water age and water use for five purging conditions: purging at regular intervals, "smart" purging (considering the time of last use), purging with different volumes of water, purging at different fixtures, and the purging with different levels of home occupancy. Higher purging frequency and volume resulted in lower water ages, but higher water use. Purging greatly reduced the variability in water ages, avoiding extreme ages entirely. Water age was minimized by scheduling the purging around occupancy behavior, such as before the occupants wake up or return from work. Scheduled purging used more water than smart purging. Purging after 12 h of nonuse used only 55% of the additional water required for purging every 12 h. Purging after 24 h of nonuse at the kitchen tap and shower used only 38% of the additional water required for purging every 24 h, while maintaining lower water ages and removing the variability in water ages. While larger purging volumes had a greater impact on water age, there were diminishing returns. Purging has a larger impact on low-occupancy homes because fixtures have less frequent use. Overall, this research provides a methodology to compare purging strategies that minimize both water age and water use. While the numerical results presented here are only valid for the specific layout and usage habits, they provide insights and trends applicable to other cases.

Legionnaires' disease in Switzerland: rationale and study protocol of a prospective national case-control and molecular source attribution study (SwissLEGIO)

Switzerland has one of the highest annual Legionnaires' disease (LD) notification rates in Europe (7.8 cases/100,000 population in 2021). The main sources of infection and the cause for this high rate remain largely unknown. This hampers the implementation of targeted Legionella spp. control efforts. The SwissLEGIO national case-control and molecular source attribution study investigates risk factors and infection sources for community-acquired LD in Switzerland. Over the duration of one year, the study is recruiting 205 newly diagnosed LD patients through a network of 20 university and cantonal hospitals. Healthy controls matched for age, sex, and residence at district level are recruited from the general population. Risk factors for LD are assessed in questionnaire-based interviews. Clinical and environmental Legionella spp. isolates are compared using whole genome sequencing (WGS). Direct comparison of sero- and sequence types (ST), core genome multilocus sequencing types (cgMLST), and single nucleotide polymorphisms (SNPs) between clinical and environmental isolates are used to investigate the infection sources and the prevalence and virulence of different Legionella spp. strains detected across Switzerland. The SwissLEGIO study innovates in combining case-control and molecular typing approaches for source attribution on a national level outside an outbreak setting. The study provides a unique platform for national Legionellosis and Legionella research and is conducted in an inter- and transdisciplinary, co-production approach involving various national governmental and national research stakeholders.

Conceptual model to inform Legionella-amoebae control, including the roles of extracellular vesicles in engineered water system infections

Extracellular vesicles (EVs or exosomes) are well described for bacterial pathogens associated with our gastrointestinal system, and more recently as a novel mechanism for environmental persistence, dissemination and infection for human enteric viruses. However, the roles played by EVs in the ancient arms race that continues between amoebae and one of their prey, Legionella pneumophila, is poorly understood. At best we know of intracellular vesicles of amoebae containing a mix of bacterial prey species, which also provides an enhanced niche for bacteriophage infection/spread. Free-living amoeba-associated pathogens have recently been recognized to have enhanced resistance to disinfection and environmental stressors, adding to previously understood (but for relatively few species of) bacteria sequestered within amoebal cysts. However, the focus of the current work is to review the likely impacts of large numbers of respiratory-sized EVs containing numerous L. pneumophila cells studied in pure and biofilm systems with mixed prey species. These encapsulated pathogens are orders of magnitude more resistant to disinfection than free cells, and our engineered systems with residual disinfectants could promote evolution of resistance (including AMR), enhanced virulence and EV release. All these are key features for evolution within a dead-end human pathogen post lung infection. Traditional single-hit pathogen infection models used to estimate the probability of infection/disease and critical environmental concentrations via quantitative microbial risk assessments may also need to change. In short, recognizing that EV-packaged cells are highly virulent units for transmission of legionellae, which may also modulate/avoid human host immune responses. Key data gaps are raised and a previous conceptual model expanded upon to clarify where biofilm EVs could play a role promoting risk as well as inform a more wholistic management program to proactively control legionellosis.

Occurrence of fungal spores in drinking water: A review of pathogenicity, odor, chlorine resistance and control strategies

Fungi in drinking water have been long neglected due to the lack of convenient analysis methods, widely accepted regulations and efficient control strategies. However, in the last few decades, fungi in drinking water have been widely recognized as opportunity pathogens that cause serious damage to the health of immune-compromised individuals. In drinking water treatment plants, fungal spores are more resistant to chlorine disinfection than bacteria and viruses, which can regrow in drinking water distribution systems and subsequently pose health threats to water consumers. In addition, fungi in drinking water may represent an ignored source of taste and odor (T&O). This review identified 74 genera of fungi isolated from drinking water and presented their detailed taxonomy, sources and biomass levels in drinking water systems. The typical pathways of exposure of water-borne fungi and the main effects on human health are clarified. The fungi producing T&O compounds and their products are summarized. Data on free chlorine or monochloramine inactivation of fungal spores and other pathogens are compared. At the first time, we suggested four chlorine-resistant mechanisms including aggregation to tolerate chlorine, strong cell walls, cellular responses to oxidative stress and antioxidation of melanin, which are instructive for the future fungi control attempts. Finally, the inactivation performance of fungal spores by various technologies are comprehensively analyzed. The purpose of this study is to provide an overview of fungi distribution and risks in drinking water, provide insight into the chlorine resistance mechanisms of fungal spores and propose approaches for the control of fungi in drinking water.

Surveillance of Legionella spp. in Open Fountains: Does It Pose a Risk?

Clusters of outbreaks or cases of legionellosis have been linked to fountains. The function of fountains, along with their inadequate design and poor sanitation, in combination with the warm Mediterranean climate, can favor the proliferation of Legionella in water systems. Public fountains in Mediterranean cities may pose a significant risk for public health due to the aerosolization of water. Nevertheless, few studies have been conducted on Legionella and the risk of infection in humans through fountains. In our study, the presence and quantity of Legionella spp. in fifteen external public fountains were investigated. Two samplings were performed in two different periods (dry and wet). Sixty samples were collected, quantified and analyzed with a culture ISO method. The operation of all fountains was evaluated twice using a standardized checklist. In accordance with their operation, a ranking factor (R factor) was suggested. Finally, based on these results, a quantitative microbial risk assessment was performed. Thirty water samples taken from the fountains (100%) during the dry sampling period were positive for Legionella (mean log concentration: 3.64 ± 0.45 cfu/L), whereas 24 water samples taken from the fountains during the wet period were Legionella-positive (mean log concentration: 2.36 ± 1.23 cfu/L). All fountains were classified as unsatisfactory according to the checklist for the evaluation of their function. A statistically significant correlation was found between Legionella concentration and the assessment score. The risk of Legionella infection was estimated in both periods, with higher risk in the dry period. The surveillance and risk assessment of Legionella spp. in the fountains of Patras confirmed a high prevalence and a high risk to public health.

Shower water contributes viable nontuberculous mycobacteria to indoor air

Nontuberculous mycobacteria (NTM) are frequently present in municipal drinking water and building plumbing, and some are believed to cause respiratory tract infections through inhalation of NTM-containing aerosols generated during showering. However, the present understanding of NTM transfer from water to air is insufficient to develop NTM risk mitigation strategies. This study aimed to characterize the contribution of shower water to the abundance of viable NTM in indoor air. Shower water and indoor air samples were collected, and 16S rRNA and rpoB genes were sequenced. The sequencing results showed that running the shower impacted the bacterial community structure and NTM species composition in indoor air by transferring certain bacteria from water to air. A mass balance model combined with NTM quantification results revealed that on average 1/132 and 1/254 of NTM cells in water were transferred to air during 1 hour of showering using a rain and massage showerhead, respectively. A large fraction of the bacteria transferred from water to air were membrane-damaged, i.e. they had compromised membranes based on analysis by live/dead staining and flow cytometry. However, the damaged NTM in air were recoverable as shown by growth in a culture medium mimicking the respiratory secretions of people with cystic fibrosis, implying a potential infection risk by NTM introduced to indoor air during shower running. Among the recovered NTM, Mycobacterium mucogenicum was the dominant species as determined by rpoB gene sequencing. Overall, this study lays the groundwork for future pathogen risk management and public health protection in the built environment.

Assessment of the risk of Legionella pneumophila in water distribution systems in hospitals of Tehran city

When a sensitive host inhales aerosols containing these bacteria, Legionella infection occurs. Therefore, monitoring and assessing Legionella in the environment and water distribution systems of such places are critical due to the prone population in hospitals. However, the health risks of Legionella bacteria in the environment are not adequately evaluated. In this study, for hospitalized patients, we performed a quantitative health risk assessment of Legionella in selected hospitals in Tehran city using two scenarios of shower and toilet faucet exposure. This study identified Legionella in 38 cases (38%) out of 100 samples collected from toilet faucets and showers in 8 hospitals. The information gathered was used for quantitative microbial risk assessment (QMRA). The microbial load transmitted by inhalation was calculated using the concentration of Legionella in water. Other exposure parameters (inhalation rate and exposure time) were obtained using information from other studies and the median length of hospital stay (3.6 days). The exponential model was used to estimate the risk of infection (γ = 0.06) due to Legionella pneumophila (L. pneumophila) inhalation for each exposure event. For the mean concentration obtained for Legionella (10³ CFU/L), the risk of infection for toilet faucets and showers was in the range of 0.23-2.3 and 3.5-21.9, respectively, per 10,000 hospitalized patients. The results were compared with the tolerable risk level of infection determined by the US EPA and WHO. The risk values exceeded the WHO values for waterborne pathogens in hospitals in both exposure scenarios. As a result, our QMRA results based on monitoring data showed that despite using treated water (from distribution networks in the urban areas) by hospitals, 38% of the samples were contaminated with Legionella, and faucets and showers can be sources of Legionella transmission. Hence, to protect the health of hospitalized patients, the risk of Legionella infection should be considered.

An application for relating Legionella shower water monitoring results to estimated health outcomes

Exposure models are useful tools for relating environmental monitoring data to expected health outcomes. The objective of this study was to (1) compare two Legionella shower exposure models, and (2) develop a risk calculator tool for relating environmental monitoring data to estimated Legionella infection risks and Legionnaires' Disease (LD) illness risks. Legionella infection risks for a single shower event were compared using two shower Legionella exposure models. These models varied in their description of partitioning of Legionella in aerosols and aerosol deposition in the lung, where Model 1 had larger and fewer aerosol ranges than Model 2. Model 2 described conventional vs. water efficient showers separately, while Model 1 described exposure for an unspecified shower type (did not describe it as conventional or water efficient). A Monte Carlo approach was used to account for variability and uncertainty in these aerosolization and deposition parameters, Legionella concentrations, and the dose-response parameter. Methods for relating infection risks to illness risks accounting for demographic differences were used to inform the risk calculator web application ("app"). Model 2 consistently estimated higher infection risks than Model 1 for the same Legionella concentration in water and estimated deposited doses with less variability. For a 7.8-min shower with a Legionella concentration of 0.1 CFU/mL, the average infection risks estimated using Model 2 were 4.8 × 10^-6 (SD=3.0 × 10^-6) (conventional shower) and 2.3 × 10^-6 (SD=1.7 × 10^-6) (water efficient). Average infection risk estimated by Model 1 was 1.1 × 10^-6 (SD=9.7 × 10^-7). Model 2 was used for app development due to more conservative risk estimates and less variability in estimated dose. While multiple Legionella shower models are available for quantitative microbial risk assessments (QMRAs), they may yield notably different infection risks for the same environmental microbial concentration. Model comparisons will inform decisions regarding their integration with risk assessment tools. The development of risk calculator tools for relating environmental microbiology data to infection risks will increase the impact of exposure models for informing water treatment decisions and achieving risk targets.

Potential environmental and health risk when returning to normal amidst COVID-19 vaccination

Due to the SARS-CoV-2 pandemic and restricted occupancy in work and school settings, there is a heightened risk for Legionella infection. An increase of stagnation in water pipe systems with limited water usage stimulates biofilm build-up, further facilitating Legionella proliferation. Individuals can inhale infected water aerosols and develop Legionellosis that can progress into mild flu-like symptoms or severe pneumonia. While SARS-CoV-2 vaccinations have been introduced globally, there is a concern for bacterial coinfections as individuals resume normal activities. Even with new SARS-CoV-2 variants circulating, Legionella persists as a public health threat as vulnerable communities' restrictions fluctuate. Proper water monitoring and management are critical while reopening communities. This article features Legionella characteristics and novel case reports amidst the pandemic. This article encourages greater awareness for building managers to minimize water stagnancy by disinfecting water distribution systems and promotes healthcare professionals to properly diagnose other illnesses during the ongoing pandemic to reduce morbidity and mortality.

Quantitative Microbial Risk Assessment Applied to Legionella Contamination on Long-Distance Public Transport

The quantitative microbial risk assessment (QMRA) framework is used for assessing health risk coming from pathogens in the environment. In this paper, we used QMRA to evaluate the infection risk of L. pneumophila attributable to sink usage in a toilet cabin on Italian long-distance public transportation (LDT). LDT has water distribution systems with risk points for Legionella proliferation, as well as premise plumbing for drinking water, but they are not considered for risk assessment. Monitoring data revealed that approximately 55% of water samples (217/398) were positive for L. pneumophila, and the most frequently isolated was L. pneumophila sg1 (64%, 139/217); therefore, such data were fitted to the best probability distribution function to be used as a stochastic variable in the QMRA model. Then, a sink-specific aerosolization ratio was applied to calculate the inhaled dose, also considering inhalation rate and exposure time, which were used as stochastic parameters based on literature data. At L. pneumophila sg1 concentration ≤100 CFU/L, health risk was approximately 1 infection per 1 million exposures, with an increase of up to 5 infections per 10,000 exposures when the concentrations were ≥10,000 CFU/L. Our QMRA results showed a low Legionella infection risk from faucets on LDT; however, it deserves consideration since LDT can be used by people highly susceptible for the development of a severe form of the disease, owing to their immunological status or other predisposing factors. Further investigations could also evaluate Legionella-laden aerosols from toilet flushing.

Demographic differences in use of household tap water in a representative sample of US adults, FallStyles 2019

Tap water that is safe to consume may cause respiratory illness (e.g., Legionnaires' disease) when water conditions allow for proliferation and aerosolization of biofilm-associated pathogens. This study assessed household tap water consumption, exposure to aerosolized tap water, and associated demographics. A nationally representative FallStyles survey administered by Porter Novelli Public Services was sent to 4,677 US adult panelists in October 2019. There were 3,624 adults who completed the survey (77.5% response rate). Respondents were asked about self-reported use of household tap water for consumption (i.e., drinking, rinsing produce, or making ice) and use through water-aerosolizing devices (e.g., showerheads, humidifiers). Demographics included gender, age, race/ethnicity, education, income, region, and health status. Weighted analyses using complex sample survey procedures were used to assess tap water exposure by route and demographics. Most US adults are exposed to aerosolized tap water through showering (80.6%), and one in five are exposed through other water-aerosolizing devices (20.3%). Consumption and showering were greatest among older, White, higher educated, and higher-income adults. Aerosolized tap water can transmit waterborne pathogens and cause respiratory illness, especially among older age groups and people with weakened immune systems. These results will help target health messages for using water-aerosolizing devices safely.

Legionella: A Promising Supplementary Indicator of Microbial Drinking Water Quality in Municipal Engineered Water Systems

Opportunistic pathogens (OPs) are natural inhabitants and the predominant disease causative biotic agents in municipal engineered water systems (EWSs). In EWSs, OPs occur at high frequencies and concentrations, cause drinking-water-related disease outbreaks, and are a major factor threatening public health. Therefore, the prevalence of OPs in EWSs represents microbial drinking water quality. Closely or routinely monitoring the dynamics of OPs in municipal EWSs is thus critical to ensuring drinking water quality and protecting public health. Monitoring the dynamics of conventional (fecal) indicators (e.g., total coliforms, fecal coliforms, and Escherichia coli) is the customary or even exclusive means of assessing microbial drinking water quality. However, those indicators infer only fecal contamination due to treatment (e.g., disinfection within water utilities) failure and EWS infrastructure issues (e.g., water main breaks and infiltration), whereas OPs are not contaminants in drinking water. In addition, those indicators appear in EWSs at low concentrations (often absent in well-maintained EWSs) and are uncorrelated with OPs. For instance, conventional indicators decay, while OPs regrow with increasing hydraulic residence time. As a result, conventional indicators are poor indicators of OPs (the major aspect of microbial drinking water quality) in EWSs. An additional or supplementary indicator that can well infer the prevalence of OPs in EWSs is highly needed. This systematic review argues that Legionella as a dominant OP-containing genus and natural inhabitant in EWSs is a promising candidate for such a supplementary indicator. Through comprehensively comparing the behavior (i.e., occurrence, growth and regrowth, spatiotemporal variations in concentrations, resistance to disinfectant residuals, and responses to physicochemical water quality parameters) of major OPs (e.g., Legionella especially L. pneumophila, Mycobacterium, and Pseudomonas especially P. aeruginosa), this review proves that Legionella is a promising supplementary indicator for the prevalence of OPs in EWSs while other OPs lack this indication feature. Legionella as a dominant natural inhabitant in EWSs occurs frequently, has a high concentration, and correlates with more microbial and physicochemical water quality parameters than other common OPs. Legionella and OPs in EWSs share multiple key features such as high disinfectant resistance, biofilm formation, proliferation within amoebae, and significant spatiotemporal variations in concentrations. Therefore, the presence and concentration of Legionella well indicate the presence and concentrations of OPs (especially L. pneumophila) and microbial drinking water quality in EWSs. In addition, Legionella concentration indicates the efficacies of disinfectant residuals in EWSs. Furthermore, with the development of modern Legionella quantification methods (especially quantitative polymerase chain reactions), monitoring Legionella in ESWs is becoming easier, more affordable, and less labor-intensive. Those features make Legionella a proper supplementary indicator for microbial drinking water quality (especially the prevalence of OPs) in EWSs. Water authorities may use Legionella and conventional indicators in combination to more comprehensively assess microbial drinking water quality in municipal EWSs. Future work should further explore the indication role of Legionella in EWSs and propose drinking water Legionella concentration limits that indicate serious public health effects and require enhanced treatment (e.g., booster disinfection).

Integrated approach for legionellosis risk analysis in touristic-recreational facilities

Legionellosis is a severe pneumonia caused by the inhalation of aerosols containing Legionella, Gram-negative bacteria present in the water systems of touristic-recreational facilities. The purpose of this study was to develop a scoring tool to predict the risk of both environmental contamination and Legionnaires' disease cases in such facilities in the Apulia region of southern Italy. We analyzed 47 structural and management parameters/risk factors related to the buildings, water systems, and air conditioning at the facilities. A Poisson regression model was used to compute an overall risk score for each facility with respect to three outcomes: water samples positive for Legionella (risk score range: 7-54), water samples positive for Legionella with an average load exceeding 1000 colony-forming units per liter (CFU/L) (risk score range: 22-179,871), and clinical cases of Legionnaire's disease (risk score range: 6-31). The cut-off values for three outcomes were determined by receiver operating characteristic curves (first outcome, samples positive for Legionella in a touristic-recreational facility: 19; second outcome, samples positive for Legionella in a touristic-recreational facility with an average load exceeding 1000 CFU/L: 2062; third outcome, clinical cases of Legionnaire's disease in a touristic-recreational facility: 22). Above these values, there was a significant probability of observing the outcome. We constructed this predictive model using 70% of a large dataset (18 years of clinical and environmental surveillance) and tested the model on the remaining 30% of the dataset to demonstrate its reliability. Our model enables the assessment of risk for a touristic facility and the creation of a conceptual framework to link the risk analysis with prevention measures.

The role of Acanthamoeba spp. in biofilm communities: a systematic review

Acanthamoeba spp. have always caused disease in immunosuppressed patients, but since 1986, they have become a worldwide public health issue by causing infection in healthy contact lens wearers. Amoebae of the Acanthamoeba genus are broadly distributed in nature, living either freely or as parasites, and are frequently associated with biofilms throughout the environment. These biofilms provide the parasite with protection against external aggression, thus favoring its increased pathogeny. This review aims to assess observational studies on the association between Acanthamoeba spp. and biofilms, opening potential lines of research on this severe ocular infection. A systematic literature search was conducted in May 2020 in the following databases: PubMed Central^®/Medline, LILACS, The Cochrane Library, and EMBASE^®. The studies were selected following the inclusion and exclusion criteria specifically defined for this review. Electronic research recovered 353 publications in the literature. However, none of the studies met the inclusion criterion of biofilm-producing Acanthamoeba spp., inferring that the parasite does not produce biofilms. Nonetheless, 78 studies were classified as potentially included regarding any association of Acanthamoeba spp. and biofilms. These studies were allocated across six different locations (hospital, aquatic, ophthalmic and dental environments, biofilms produced by bacteria, and other places). Acanthamoeba species use biofilms produced by other microorganisms for their benefit, in addition to them providing protection to and facilitating the dissemination of pathogens residing in them.

Secondary transmission of SARS-CoV-2 through wastewater: Concerns and tactics for treatment to effectively control the pandemic

The SARS-CoV-2 virus has spread globally and has severely impacted public health and the economy. Hand hygiene, social distancing, and the usage of personal protective equipment are considered the most vital tools in controlling the primary transmission of the virus. Converging evidence indicated the presence of SARS-CoV-2 in wastewater and its persistence over several days, which may create secondary transmission of the virus via waterborne and wastewater pathways. Although, researchers have started focusing on this mode of virus transmission, limited knowledge and societal unawareness of the transmission through wastewater may lead to significant increases in the number of positive cases. To emphasize the severe issue of virus transmission through wastewater and create societal awareness, we present a state of the art critical review on transmission of SARS-CoV-2 in wastewater and the potential remedial strategies to effectively control the viral spread and safeguard society. For low-income countries with high population densities, it is suggested to identify the virus in large scale municipal wastewater plants before following up with one-to-one testing for effective control of the secondary transmission. Ultrafiltration is an effective method for wastewater treatment and usually more than 4 logs of virus removal are achieved while safeguarding good protein permeability. Decentralized wastewater treatment facilities using solar-assisted disinfestation methods are most economical and can be effectively used in hospitals, isolation wards, and medical centers for reducing the risk of transmission from high local concentration sites, especially in tropical countries with abundant solar energy. Disinfection with chlorine, sodium hypochlorite, benzalkonium chloride, and peracetic acid have shown potential in terms of virucidal properties. Biological wastewater treatment using micro-algae will be highly effective in removal of virus and can be incorporated into membrane bio-reaction to achieve excellent virus removal rate. Though promising results have been shown by initial research for inactivation of SARS-CoV-2 in wastewater using physical, chemical and biological based treatment methods, there is a pressing need for extensive investigation of COVID-19 specific disinfectants with appropriate concentrations, their environmental implications, and regular monitoring of transmission. Effective wastewater treatment methods with high virus removal capacity and low treatment costs should be selected to control the virus spread and safeguard society from this deadly virus.

COVID-19 infection risk from exposure to aerosols of wastewater treatment plants

Fecal shedding of SARS-CoV-2 from COVID-19 patients and presence of the viral RNA in wastewater have extensively been reported. Some wastewater treatment plant (WWTP) processes generate aerosols which have the potential to transmit pathogenic microorganisms and present a health risk for exposed individuals. We analyzed the presence of viral RNA of SARS-CoV-2 in raw wastewater and air samples of WWTPs. The risk that may arise from exposure to virus-contaminated aerosols of wastewater was estimated by developing a quantitative microbial risk analysis (QMRA) method. SARS-CoV-2 was detected in 9 of 24 (37.5%) wastewater samples with a concentration about 10⁴ genomic copies L^-1. The viral RNA was also detected in 40% (6/15) of air samples. QMRA analysis showed a relatively high risk of SARS-CoV-2 infection for wastewater workers via exposure to the viral aerosols. The estimated annual infection risk ranged from 1.1 × 10^-2 to 2.3 × 10^-2 per person per year (PPPY) for wastewater workers which was higher than the reference level recommended by WHO (10^-3 pppy). However, due to the lack of data on survival of SARS-CoV-2 in wastewater and its fate in aerosolized state, more research is needed to determine the importance of wastewater in transmission of COVID-19.

Re-opening hairdressing salons, barber shops and gyms following COVID-19 lockdown: reducing risks from Legionella species through successful domestic steam disinfection of showerheads

Given the importance of disinfecting showerheads from Legionella species and the lack of instructions as to how to successfully achieve this, the aim of this study was to examine the ability of domestic steam disinfection to successfully disinfect showerheads from Legionella species. Steam disinfection of Legionella pneumophila [n=3; L. pneumophila serogroup 2–15 (wildtype environmental water isolate); L. pneumophila serogroup 1 NCTC11192 (reference strain); L. pneumophila serogroup 1 (wildtype environmental water isolate)], L. erythra (wildtype environmental water isolate) and L. bozemanii CRM11368M (reference strain) were examined in this study. Steam disinfection employing a baby bottle steam disinfector device eradicated all Legionella organisms tested. Steam disinfection, when performed properly under the manufacturer’s instructions, offers a relatively inexpensive, simple, versatile and widely available technology for the elimination of Legionella species from contaminated showerheads. We therefore advocate the employment of such devices to regularly disinfect showerheads and shower tubing in hairdressing salons, barber shops and gyms, as a critical control in the elimination of these organisms from these sources, thereby enhancing customer/client/staff safety.

Assessment of hygienic conditions of recreational facility restrooms: an integrated approach

Introduction

Microbiological quality of recreational environments included restrooms, is generally assessed by water and surface monitoring. In this study, an environmental monitoring, conducted in spring, of swimming pool restrooms of a recreation center located in the Marche region has been carried out. Seven water samples and seven surface swabs were collected. Moreover, six air samples have been included. The aim of this study was to evaluate if air microbiological monitoring, along with molecular detection in real-time PCR, could give additional useful information about the hygienic conditions of the facility.

Methods

Heterotrophic Plate Count (HPC) both at 22°C (psychrophilic) and 37°C (mesophilic) was determined by separate cultures in all samples. The presence of Legionella pneumophila and Pseudomonas aeruginosa was evaluated by both culture and real-time PCR.

Results

The analysis of shower water recorded a HPC load of mesophilic bacteria (37°C) more than 10-fold higher in men restroom, respect to women’s one (> 100 vs < 10 CFU/ml), while in air samples was between < 100 and > 500. Concerning pathogen presence, both species Legionella pneumophila and Pseudomonas aeruginosa were detected only in men restroom, but in different sample types by using different methods (culture and real-time PCR).

Conclusions

Air sampling may offer the advantage of giving more representative data about microbial presence in restrooms, including bacterial species transmitted through aerosol, like Legionella. Moreover, the concurrent use of molecular and microbiological detection in an integrated approach could offer the advantage of greater sensitivity.

Quantifying the risk of indoor drainage system in multi-unit apartment building as a transmission route of SARS-CoV-2

The COVID-19 pandemic has had a profound impact on human society. The isolation of SARS-CoV-2 from patients' feces on human cell line raised concerns of possible transmission through human feces including exposure to aerosols generated by toilet flushing and through the indoor drainage system. Currently, routes of transmission, other than the close contact droplet transmission, are still not well understood. A quantitative microbial risk assessment was conducted to estimate the health risks associated with two aerosol exposure scenarios: 1) toilet flushing, and 2) faulty connection of a floor drain with the building's main sewer pipe. SARS-CoV-2 data were collected from the emerging literature. The infectivity of the virus in feces was estimated based on a range of assumption between viral genome equivalence and infectious unit. The human exposure dose was calculated using Monte Carlo simulation of viral concentrations in aerosols under each scenario and human breathing rates. The probability of COVID-19 illness was generated using the dose-response model for SARS-CoV-1, a close relative of SARS-CoV-2, that was responsible for the SARS outbreak in 2003. The results indicate the median risks of developing COVID-19 for a single day exposure is 1.11 × 10-10 and 3.52 × 10-11 for toilet flushing and faulty drain scenario, respectively. The worst case scenario predicted the high end of COVID-19 risk for the toilet flushing scenario was 5.78 × 10-4 (at 95th percentile). The infectious viral loads in human feces are the most sensitive input parameter and contribute significantly to model uncertainty.

Differential Bacterial Predation by Free-Living Amoebae May Result in Blooms of Legionella in Drinking Water Systems

Intracellular growth of pathogenic Legionella in free-living amoebae (FLA) results in the critical concentrations that are problematic in engineered water systems (EWS). However, being amoeba-resistant bacteria (ARB), how Legionella spp. becomes internalized within FLA is still poorly understood. Using fluorescent microscopy, we investigated in real-time the preferential feeding behavior of three water-related FLA species, Willaertia magna, Acanthamoeba polyphaga, and Vermamoeba vermiformis regarding Legionella pneumophila and two Escherichia coli strains. Although all the studied FLA species supported intracellular growth of L. pneumophila, they avoided this bacterium to a certain degree in the presence of E. coli and mostly fed on it when the preferred bacterial food-sources were limited. Moreover, once L. pneumophila were intracellular, it inhibited digestion of co-occurring E. coli within the same trophozoites. Altogether, based on FLA–bacteria interactions and the shifts in microbial population dynamics, we propose that FLA’s feeding preference leads to an initial growth of FLA and depletion of prey bacteria, thus increases the relative abundance of Legionella and creates a “forced-feeding” condition facilitating the internalization of Legionella into FLA to initiate the cycles of intracellular multiplication. These findings imply that monitoring of FLA levels in EWS could be useful in predicting possible imminent high occurrence of Legionella.

Interactions between Human Reovirus and Free-Living Amoebae: Implications for Enteric Virus Disinfection and Aquatic Persistence

Free-living amoebae (FLA) are ubiquitous protozoa in aquatic/soil habitats and known to resist various disinfection methods commonly used in drinking and wastewater treatment plants. Reoviruses are emerging as useful infectious enteric virus indicators of wastewater treatment efficacy. The possible enhanced protection FLA may provide reoviruses, however, has not been previously described. Using an infectious clinical reovirus isolate in coculture with three FLA, namely, Vermamoeba vermiformis, Acanthamoeba polyphaga, and Willaertia magna, we followed reovirus persistence (by quantitative reverse transcription polymerase chain reaction (RT-qPCR)) and infectivity (TCID₅₀). Virions present in samples persisted over the experimental time period, with most virions remaining infectious. Surprisingly, electron microscopy revealed virions accumulated within the nucleus of amoebae. The current work appears to be the first report of reovirus being internalized within FLA and remaining infectious, providing a previously unreported environmental reservoir and potential mode of dissemination. FLA also appeared to be providing some logs in protection to internalized viruses during UV irradiation, which if not accounted for when determining UV dosage needed for sufficient disinfection may result in unintentional release of pathogens into surrounding water systems.

Large community-acquired Legionnaires' disease outbreak caused by Legionella pneumophila serogroup 1, Italy, July to August 2018

In July 2018, a large outbreak of Legionnaires' disease (LD) caused by Legionella pneumophila serogroup 1 (Lp1) occurred in Bresso, Italy. Fifty-two cases were diagnosed, including five deaths. We performed an epidemiological investigation and prepared a map of the places cases visited during the incubation period. All sites identified as potential sources were investigated and sampled. Association between heavy rainfall and LD cases was evaluated in a case-crossover study. We also performed a case-control study and an aerosol dispersion investigation model. Lp1 was isolated from 22 of 598 analysed water samples; four clinical isolates were typed using monoclonal antibodies and sequence-based typing. Four Lp1 human strains were ST23, of which two were Philadelphia and two were France-Allentown subgroup. Lp1 ST23 France-Allentown was isolated only from a public fountain. In the case-crossover study, extreme precipitation 5-6 days before symptom onset was associated with increased LD risk. The aerosol dispersion model showed that the fountain matched the case distribution best. The case-control study demonstrated a significant eightfold increase in risk for cases residing near the public fountain. The three studies and the matching of clinical and environmental Lp1 strains identified the fountain as the source responsible for the epidemic.

Effect of disinfectant residuals on infection risks from Legionella pneumophila released by biofilms grown under simulated premise plumbing conditions

The ubiquitous presence of biofilms in premise plumbing and stagnation, which commonly occurs in premise plumbing, can exacerbate the decay of chlorine residual in drinking water. Using biofilms grown in a simulated premise plumbing setup fed directly with freshly treated water at two full-scale water treatment plants, we previously determined the mass transfer coefficients for chlorine decay in premise plumbing. These coefficients coupled with inactivation kinetics of L. pneumophila released from biofilms reported previously were integrated into a Monte Carlo framework to estimate the infection risk of biofilm-derived L. pneumophila from 1 to 48 h of stagnation. The annual infection risk was significantly higher when water stayed stagnant for up to 48 h in pipes covered internally with biofilms, compared to clean pipes without biofilms. The decay of residual chlorine due to biofilms during 48-hour stagnation led to up to 6 times increase in the annual infection risk compared to the case where biofilms was absent. Global sensitivity analysis revealed that the rate of L. pneumophila detachment from biofilms and the decay of chlorine residual during stagnation are the two most important factors influencing the infection risks. Stagnation caused by water use patterns and water-saving devices in the premise plumbing can lead to increased infection risk by biofilm-derived L. pneumophila. Overall, this study's findings suggested that biofilms could induce chlorine decay and consequently increase L. pneumophila infection risk. Thus, reducing stagnation, maintaining residual chlorine, and suppressing biofilm growth could contribute to better management of L. pneumophila infection risk.

A valuable experimental setup to model exposure to Legionella's aerosols generated by shower-like systems

The mechanism underlying Legionella aerosolization and entry into the respiratory tract remains poorly documented. In previous studies, we characterized the aerodynamic behaviour of Legionella aerosols and assessed their regional deposition within the respiratory tract using a human-like anatomical model. The aim of this study was to assess whether this experimental setup could mimic the exposure to bioaerosols generated by showers. To achieve this objective we performed experiments to measure the mass median aerodynamic diameter (MMAD) as well as the emitted dose and the physiological state of the airborne bacteria generated by a shower and two nebulizers (vibrating-mesh and jet nebulizers). The MMADs of the dispersed bioaerosols were characterized using a 12-stage cascade low-pressure impactor. The amount of dispersed airborne bacteria from a shower was quantified using a Coriolis® Delta air sampler and compared to the airborne bacteria reaching the thoracic region in the experimental setup. The physiological state and concentration of airborne Legionella were assessed by qPCR for total cells, culture for viable and cultivable Legionella (VC), and flow cytometry for viable but non-cultivable Legionella (VBNC). In summary, the experimental setup developed appears to mimic the bioaerosol emission of a shower in terms of aerodynamic size distribution. Compared to the specific case of a shower used as a reference in this study, the experimental setup developed underestimates by 2 times (when the jet nebulizer is used) or overestimates by 43 times (when the vibrating-mesh nebulizer is used) the total emitted dose of airborne bacteria. To our knowledge, this report is the first showing that an experimental model mimics so closely an exposure to Legionella aerosols produced by showers to assess human lung deposition and infection in well-controlled and safe conditions.

Enteric Pathogen Treatment Requirements for Nonpotable Water Reuse Despite Limited Exposure Data

Exposure factors (e.g., ingestion volume and frequency) are required to establish risk-based treatment requirements (i.e., log10 reduction targets (LRTs)) for enteric pathogens using quantitative microbial risk assessment (QMRA). However, data to Wastewater characterize nonpotable exposure factors are sparse. We calculated graywater and wastewater nonpotable LRTs (corresponding to 10-4 infections per person per year) for uses missing detailed exposure data (including showering and decorative fountain) and across a range of exposure factors. The LRTs decreased linearly toward zero as the log10 transformed volume or the frequency of reuse decreased. When nonroutine exposure was included, representing either accidental ingestion from misuse or cross-connection between potable and nonpotable waters, the LRTs remained high, even as the routine ingestion volume decreased. Therefore, uses with small anticipated routine ingestion volumes (i.e., roughly <10-5 L), e.g., domestic indoor or decorative fountain uses, share common LRTs, and further refinement of the routine exposure is of limited value. Additional data to characterize nonroutine exposures and uses with high routine ingestion, e.g., showering, remain valuable to better estimate LRTs. These results will assist regulators in the selection of LRTs for nonpotable uses that lack detailed exposure factor characterizations.

An Advanced Risk Modeling Method to Estimate Legionellosis Risks Within a Diverse Population

Quantitative microbial risk assessment (QMRA) is a computational science leveraged to optimize infectious disease controls at both population and individual levels. Often, diverse populations will have different health risks based on a population’s susceptibility or outcome severity due to heterogeneity within the host. Unfortunately, due to a host homogeneity assumption in the microbial dose-response models’ derivation, the current QMRA method of modeling exposure volume heterogeneity is not an accurate method for pathogens such as Legionella pneumophila. Therefore, a new method to model within-group heterogeneity is needed. The method developed in this research uses USA national incidence rates from the Centers for Disease Control and Prevention (CDC) to calculate proxies for the morbidity ratio that are descriptive of the within-group variability. From these proxies, an example QMRA model is developed to demonstrate their use. This method makes the QMRA results more representative of clinical outcomes and increases population-specific precision. Further, the risks estimated demonstrate a significant difference between demographic groups known to have heterogeneous health outcomes after infection. The method both improves fidelity to the real health impacts resulting from L. pneumophila infection and allows for the estimation of severe disability-adjusted life years (DALYs) for Legionnaires’ disease, moderate DALYs for Pontiac fever, and post-acute DALYs for sequela after recovering from Legionnaires’ disease.

Legionella pneumophila as a Health Hazard to Miners: A Pilot Study of Water Quality and QMRA

Legionella pneumophila (L. pneumophila), the causative agent of legionellosis, is an aquatic bacterium that grows in warm water. Humans are only presented with a health risk when aerosolized water containing L. pneumophila is inhaled. In mining operations, aerosolized water is used as dust control and as part of the drilling operations, a currently ignored exposure route. This study characterized L. pneumophila concentrations in the mine's non-potable water and the relationship between L. pneumophila and chlorine concentrations. These concentrations informed a quantitative microbial risk assessment (QMRA) model to estimate the infection risk to miners exposed to aerosolized water containing L. pneumophila. Fourteen water samples were collected from seven locations at a mine and analyzed for temperature, pH, chlorine, and L. pneumophila serogroup. Most samples (93%) tested positive for L. pneumophila cells. The faucet from the sprinkler system on the adit level (entrance to the underground mine levels) showed the highest concentration of L. pneumophila (8.35 × 104 MPN/L). Disability adjusted life years (DALYs) were estimated in the QMRA model and showed that the risk for all miners was significantly lower (p < 0.0001) with the ventilation system on than when the system was off. Our study showed that the use of a ventilation system at the adit level of the mine reduced the risk of infection with aerosolized L. pneumophila.

Quantitative microbial risk assessment of Legionella pneumophila in a drinking water supply system in Israel

Legionella pneumophila cause human infections via inhalation of contaminated water aerosols, resulting in severe pneumonia. Legionella spp. prevalence was monitored in a drinking-water distribution system (DWDS) in Northern Israel. Five points (toilet faucets and showers) were sampled seasonally along a three years period. Toilet faucets and shower use, both generating aerosols, are known transmission routes for this pathogen and thus, present a potential health risk. Quantitative Microbial Risk Assessment (QMRA) was applied in order to assess the health risks posed by Legionella for these two exposure scenarios, while considering Legionella seasonality. The obtained results were compared with estimated tolerable risk levels of infection and of disease set by the USEPA and WHO. Both limits were expressed as Disability-Adjusted Life Years index (DALY) being 1 × 10^-4 and 1 × 10^-6, respectively. The QMRA revealed that the annual risk levels for both faucets and showers use exceeded the acceptable risk of infection with an average of 5.52 × 10^-4 and 2.37 × 10^-3 DALY'S per person per year, respectively. Annual risk levels were stable with no significant differences between the three years. Risk levels varied significantly between seasons by up to three orders of magnitude. Risk levels were highest during summer, autumn, and lowest during winter. The highest seasonal infection risk values were found in summer for both faucets and showers, which corresponded to 8.09 × 10^-4 and 2.75 × 10^-3 DALY'S per person per year, respectively. In conclusion, during summer and autumn there is a significant increase of the infection risk associated with exposure to Legionella-contaminated aerosols, in the studied water system. Public health assessment and prevention measures should focus on these seasons.

Long-term persistence of infectious Legionella with free-living amoebae in drinking water biofilms

Prolific growth of pathogenic Legionella pneumophila within engineered water systems and premise plumbing, and human exposure to aerosols containing this bacterium results in the leading health burden of any water-related pathogen in developed regions. Ecologically, free-living amoebae (FLA) are an important group of the microbial community that influence biofilm bacterial diversity in the piped-water environment. Using fluorescent microscopy, we studied in-situ the colonization of L. pneumophila in the presence of two water-related FLA species, Willaertia magna and Acanthamoeba polyphaga in drinking water biofilms. During water flow as well as after periods of long-stagnation, the attachment and colonization of L. pneumophila to predeveloped water-biofilm was limited. Furthermore, W. magna and A. polyphaga showed no immediate interactions with L. pneumophila when introduced to the same natural biofilm environment. A. polyphaga encysted within 5-7 d after introduction to the tap-water biofilms and mostly persisted in cysts till the end of the study period (850 d). W. magna trophozoites, however, exhibited a time delay in feeding on Legionella and were observed with internalized L. pneumophila cells after 3 weeks from their introduction to the end of the study period and supported putative (yet limited) intracellular growth. The culturable L.pneumophila in the bulk water was reduced by 2-log over 2 years at room temperature but increased (without a change in mip gene copies by qPCR) when the temperature was elevated to 40 °C within the same closed-loop tap-water system without the addition of nutrients or fresh water. The overall results suggest that L. pneumophila maintains an ecological balance with FLA within the biofilm environment, and higher temperature improve the viability of L. pneumophila cells, and intracellular growth of Legionella is possibly cell-concentration dependent. Observing the preferential feeding behavior, we hypothesize that an initial increase of FLA numbers through feeding on a range of other available bacteria could lead to an enrichment of L. pneumophila, and later force predation of Legionella by the amoeba trophozoites results in rapid intracellular replication, leading to problematic concentration of L. pneumophila in water. In order to find sustainable control options for legionellae and various other saprozoic, amoeba-resisting bacterial pathogens, this work emphasizes the need for better understanding of the FLA feeding behavior and the range of ecological interactions impacting microbial population dynamics within engineered water systems.

Risk-Based Critical Concentrations of Legionella pneumophila for Indoor Residential Water Uses

Legionella spp. is a key contributor to the United States waterborne disease burden. Despite potentially widespread exposure, human disease is relatively uncommon, except under circumstances where pathogen concentrations are high, host immunity is low, or exposure to small-diameter aerosols occurs. Water quality guidance values for Legionella are available for building managers but are generally not based on technical criteria. To address this gap, a quantitative microbial risk assessment (QMRA) was conducted using target risk values in order to calculate corresponding critical concentrations on a per-fixture and aggregate (multiple fixture exposure) basis. Showers were the driving indoor exposure risk compared to sinks and toilets. Critical concentrations depended on the dose response model (infection vs clinical severity infection, CSI), risk target used (infection risk vs disability adjusted life years [DALY] on a per-exposure or annual basis), and fixture type (conventional vs water efficient or "green"). Median critical concentrations based on exposure to a combination of toilet, faucet, and shower aerosols ranged from ∼10^-2 to ∼10⁰ CFU per L and ∼10¹ to ∼10³ CFU per L for infection and CSI dose response models, respectively. As infection model results for critical L. pneumophila concentrations were often below a feasible detection limit for culture-based assays, the use of CSI model results for nonhealthcare water systems with a 10^-6 DALY pppy target (the more conservative target) would result in an estimate of 12.3 CFU per L (arithmetic mean of samples across multiple fixtures and/or over time). Single sample critical concentrations with a per-exposure-corrected DALY target at each conventional fixture would be 1.06 × 10³ CFU per L (faucets), 8.84 × 10³ CFU per L (toilets), and 14.4 CFU per L (showers). Using a 10^-4 annual infection risk target would give a 1.20 × 10³ CFU per L mean for multiple fixtures and single sample critical concentrations of 1.02 × 10⁵, 8.59 × 10⁵, and 1.40 × 10³ CFU per L for faucets, toilets, and showers, respectively. Annual infection risk-based target estimates are in line with most current guidance documents of less than 1000 CFU per L, while DALY-based guidance suggests lower critical concentrations might be warranted in some cases. Furthermore, approximately <10 CFU per mL L. pneumophila may be appropriate for healthcare or susceptible population settings. This analysis underscores the importance of the choice of risk target as well as sampling program considerations when choosing the most appropriate critical concentration for use in public health guidance.

Effect of sequential UV/free chlorine disinfection on opportunistic pathogens and microbial community structure in simulated drinking water distribution systems

Drinking water distribution systems (DWDS) may be a "Trojan Horse" for some waterborne diseases caused by opportunistic pathogens (OPs). In this study, two simulated DWDS inoculated with groundwater were treated with chlorine (Cl₂) and ultraviolet/chlorine (UV/Cl₂) respectively to compare their effects on the OPs distributed in four different phases (bulk water, biofilms, corrosion products, and loose deposits) of DWDS. 16S rRNA genes sequencing and qPCR were used to profile microbial community and quantify target genes of OPs, respectively. Results showed that UV/Cl₂ was more effective than single Cl₂ to control the regrowth of OPs in the water with the same residual chlorine concentration. However, the OPs inhabiting the biofilms, corrosion products, and loose deposits seemed to be tolerant to UV/Cl₂ and Cl₂, demonstrating that OPs residing in these phases were resistant to the disinfection processes. Some significant microbial correlations between OPs and Acanthamoeba were found by Spearman correlative analysis (p < 0.05), demonstrating that the ecological interactions may exist in the DWDS. 16S rRNA genes sequencing of water samples revealed a significant different microbial community structure between UV/Cl₂ and Cl₂. This study may give some implications for controlling the OPs in the DWDS disinfected with UV/Cl₂.

Legionella occurrence in municipal and industrial wastewater treatment plants and risks of reclaimed wastewater reuse: Review

Wastewater treatment plants (WWTPs) have been identified as confirmed but until today underestimated sources of Legionella, playing an important role in local and community cases and outbreaks of Legionnaires' disease. In general, aerobic biological systems provide an optimum environment for the growth of Legionella due to high organic nitrogen and oxygen concentrations, ideal temperatures and the presence of protozoa. However, few studies have investigated the occurrence of Legionella in WWTPs, and many questions in regards to the interacting factors that promote the proliferation and persistence of Legionella in these treatment systems are still unanswered. This critical review summarizes the current knowledge about Legionella in municipal and industrial WWTPs, the conditions that might support their growth, as well as control strategies that have been applied. Furthermore, an overview of current quantification methods, guidelines and health risks associated with Legionella in reclaimed wastewater is also discussed in depth. A better understanding of the conditions promoting the occurrence of Legionella in WWTPs will contribute to the development of improved wastewater treatment technologies and/or innovative mitigation approaches to minimize future Legionella outbreaks.

Primary Colonizing Betaproteobacteriales Play a Key Role in the Growth of Legionella pneumophila in Biofilms on Surfaces Exposed to Drinking Water Treated by Slow Sand Filtration

Slow sand filtration with extensive pretreatment reduces the microbial growth potential of drinking water to a minimum level at four surface water supplies in The Netherlands. The potential of these slow sand filtrates (SSFs) to promote microbial growth in warm tap water installations was assessed by measuring biofilm formation and growth of Legionella bacteria on glass and chlorinated polyvinylchloride (CPVC) surfaces exposed to SSFs at 37 ± 2°C in a model system for up to six months. The steady-state biofilm concentration ranged from 230 to 3,980 pg ATP cm^-2 on glass and 1.4 (±0.3)-times-higher levels on CPVC. These concentrations correlated significantly with the assimilable organic carbon (AOC) concentrations of the warm water (8 to 24 µg acetate-C equivalents [ac-C eq] liter^-1), which were raised about 2 times by mixing cold and heated (70°C) SSFs. All biofilms supported growth of Legionella pneumophila with maximum concentrations ranging from 6 × 10² to 1.5 × 10⁵ CFU cm^-2 Biofilms after ≤50 days of exposure were predominated by Betaproteobacteriales, mainly Piscinibacter, Caldimonas, Methyloversatilis, and an uncultured Rhodocyclaceae bacterium. These rapidly growing primary colonizers most likely served as prey for the host amoebae of L. pneumophila Alphaproteobacteria, mostly Xanthobacteraceae, e.g., Bradyrhizobium, Pseudorhodoplanes, and other amoeba-resistant bacteria, accounted for 37.5% of the clones retrieved. A conceptual model based on a quadratic relationship between the L. pneumophila colony count and the biofilm concentration under steady-state conditions is used to explain the variations in the Legionella CFU pg^-1 ATP ratios in the biofilms.IMPORTANCE Proliferation of L. pneumophila in premise plumbing poses a public health threat. Extended water treatment using physicochemical and biofiltration processes, including slow sand filtration, at four surface water supplies in The Netherlands reduces the microbial growth potential of the treated water to a minimum level, and the distributed drinking water complies with high quality standards. However, heating of the water in warm tap water installations increases the concentration of easily assimilable organic compounds, thereby promoting biofilm formation and growth of L. pneumophila Prevention of biofilm formation in plumbing systems by maintenance of a disinfectant residual during distribution and/or further natural organic matter (NOM) removal is not feasible in the supplies studied. Temperature management in combination with optimized hydraulics and material selection are therefore essential to prevent growth of L. pneumophila in premise plumbing systems. Still, reducing the concentration of biodegradable compounds in drinking water by appropriate water treatment is important for limiting the Legionella growth potential.

Effects of Chloramine and Coupon Material on Biofilm Abundance and Community Composition in Bench-Scale Simulated Water Distribution Systems and Comparison with Full-Scale Water Mains

The vast majority of bacteria in drinking water distribution systems (DWDSs) reside in biofilms on the interior walls of water mains. Little is known about how water quality conditions affect water-main biofilms because of the inherent limitations in experimenting with drinking water supplies and accessing the water mains for sampling. Bench-scale reactors permit experimentation and ease of biofilm sampling, yet questions remain as to how well biofilms in laboratory reactors represent those on water mains. In this study, the effects of DWDS pipe materials and chloramine residual on biofilms were investigated by cultivating biofilms on cement, polyvinyl chloride, and high density polyethylene coupons in CDC reactors for up to 28 months in the presence of chloraminated or dechlorinated tap water. The bench-scale biofilm microbiomes were then compared with the microbiome on a water main from the full-scale system that supplied the water to the reactors. The presence of a chloramine residual (1.74 ± 0.21 mg/L) suppressed biofilm accumulation and selected for Mycobacterium-like and Sphingopyxis-like operational taxonomic units (OTUs) while the destruction of the chloramine residual resulted in a significant increase in biomass quantity and a shift toward a more diverse community dominated by Nitrospira-like OTUs, which, our results suggest, may be complete ammonia oxidizers (comammox). Coupon material, however, had a relatively minor effect on the abundance and community composition of the biofilm bacteria. Although biofilm communities from the chloraminated water reactor and the water mains shared some dominant populations (namely, Mycobacterium- and Nitrosomonas-like OTUs), the communities were significantly different. This manuscript provides novel insights into the effects of dechlorination and pipe material on biofilm community composition. Furthermore, to our knowledge, it is the first study to compare biofilm in a tap water-fed, bench-scale simulated distribution system to biofilm on water mains from the full-scale system supplying the tap water.

Persistence of infectious Enterovirus within free-living amoebae - A novel waterborne risk pathway?

Free-living amoebae (FLA) are phagocytic protozoa found in natural and engineered water systems. They can form disinfectant-resistant cysts, which can harbor various human pathogenic bacteria, therefore providing them with a means of environmental persistence and dispersion through water distribution and other engineered water systems. The association of FLA with human viruses has been raised, but the limited data on the persistence of infectious virions within amoebae leaves this aspect unresolved. Enteroviruses can cause a wide range of illness and replicate in human respiratory and gastrointestinal tracts, both of which could be exposed through contact with contaminated waters if virus detection and removal are compromised by virion internalization in free-living protozoa. This is especially problematic for high-risk contaminants, such as coxsackieviruses, representative members of the Enterovirus genus that are likely infectious at low doses and cause a variety of symptoms to a vulnerable portion of the population (particularly infants). To investigate Enterovirus persistence within free-living amoebae we co-cultured an infectious clinical coxsackievirus B5 (CVB5) isolate, with the commonly reported tap water amoeba Vermamoeba vermiformis, after which we tracked virus localization and persistence in co-culture over time through a combination of advanced imaging, molecular and cell culture assays. Our results clearly demonstrate that infectious CVB5 can persist in all life stages of the amoebae without causing any visible injury to them. We also demonstrated that the amoeba generated vesicles containing virions that were expelled into the bulk liquid surroundings, a finding previously described for FLA-bacteria interactions, but not for FLA and human pathogenic viruses. Therefore, our findings suggest that the ability of CVB5 to persist in V. vermiformis could be a novel waterborne risk pathway for the persistence and dispersion of infectious human enteric viruses through water systems.

Searching for Activity Markers that Approximate (VBNC) Legionella pneumophila Infectivity in Amoeba after Ultraviolet (UV) Irradiation

Legionella pneumophila is an increasingly recognized threat to public health via aerosol exposures; with a variety of control measures including: water temperature/flow management and free chlorine used to reduce the risk of infection within healthcare centers. Despite these efforts, L. pneumophila often recolonizes plumbing systems after specific treatments, which prompted us to examine ultraviolet (UV) irradiation for a point-of-use, secondary control measure. Currently, there is no data on the efficacy of high (>254 nm) wavelength UV-C (100–280 nm) light inactivation of L. pneumophila with resuscitation of viable but non-culturable (VBNC) cells. We report for the first time L. pneumophila dose-responses for 268.6 nm and 288.6 nm UV-C, as compared to 256 nm, and demonstrate UV induced VBNC L. pneumophila remaining infectious to Acanthamoeba polyphaga during co-culture experiments. Findings were correlated to molecular-based activity assays to identify additional measures of L. pneumophila viability following UV disinfection compared to culture. A collection of viability markers may provide a more representative measure of risk compared to current culture-based detection, since UV-C irradiated L. pneumophila lose culturability, yet retain activity, increased ATP production, and the ability to be resuscitated by amoeba co-culture. This finding is significant as it identifies potential concern from VBNC cells following UV-C disinfection and the need for further research into the efficacy of UV inactivation as a point-of-use application for L. pneumophila control and management.

Occurrence of Legionella spp. in Water-Main Biofilms from Two Drinking Water Distribution Systems

The maintenance of a chlorine or chloramine residual to suppress waterborne pathogens in drinking water distribution systems is common practice in the United States but less common in Europe. In this study, we investigated the occurrence of Bacteria and Legionella spp. in water-main biofilms and tap water from a chloraminated distribution system in the United States and a system in Norway with no residual using real-time quantitative polymerase chain reaction (qPCR). Despite generally higher temperatures and assimilable organic carbon levels in the chloraminated system, total Bacteria and Legionella spp. were significantly lower in water-main biofilms and tap water of that system ( p < 0.05). Legionella spp. were not detected in the biofilms of the chloraminated system (0 of 35 samples) but were frequently detected in biofilms from the no-residual system (10 of 23 samples; maximum concentration = 7.8 × 10⁴ gene copies cm^-2). This investigation suggests water-main biofilms may serve as a source of Legionella for tap water and premise plumbing systems, and residual chloramine may aid in reducing their abundance.

MetaCompare: a computational pipeline for prioritizing environmental resistome risk

The spread of antibiotic resistance is a growing public health concern. While numerous studies have highlighted the importance of environmental sources and pathways of the spread of antibiotic resistance, a systematic means of comparing and prioritizing risks represented by various environmental compartments is lacking. Here, we introduce MetaCompare, a publicly available tool for ranking 'resistome risk', which we define as the potential for antibiotic resistance genes (ARGs) to be associated with mobile genetic elements (MGEs) and mobilize to pathogens based on metagenomic data. A computational pipeline was developed in which each ARG is evaluated based on relative abundance, mobility, and presence within a pathogen. This is determined through the assembly of shotgun sequencing data and analysis of contigs containing ARGs to determine if they contain sequence similarity to MGEs or human pathogens. Based on the assembled metagenomes, samples are projected into a 3-dimensionalhazard space and assigned resistome risk scores. To validate, we tested previously published metagenomic data derived from distinct aquatic environments. Based on unsupervised machine learning, the test samples clustered in the hazard space in a manner consistent with their origin. The derived scores produced a well-resolved ascending resistome risk ranking of: wastewater treatment plant effluent, dairy lagoon, and hospital sewage.

Indoor release of asbestiform fibers from naturally contaminated water and related health risk

This study investigates the occurrence of airborne asbestiform fibers released in indoor ambient due to the use of asbestos naturally contaminated water. Some experiments employed a laboratory physical model using an ultrasonic humidifier charged with contaminated groundwater. Other experiments were carried out at full scale to assess the release of asbestiform fibers during showering. Obtained results show that the concentration of the airborne asbestiform fibers released in the bathroom during showering is higher than the limit value set by the European and Italian Regulations, while the concentration of fibers released by the humidifier is much lower. However, it is noteworthy that the use of the humidifier at high exposure time results in similar health risk. Strong correlations were found between the concentration of the airborne asbestiform fibers and a novel surrogate parameter (i.e. the exposure-specific-water-consumption). These correlations can be used to monitor the asbestiform fibers concentration at varying operating conditions and therefore, to control the resulting health risk.

Health risks from exposure to Legionella in reclaimed water aerosols: Toilet flushing, spray irrigation, and cooling towers

The use of reclaimed water brings new challenges for the water industry in terms of maintaining water quality while increasing sustainability. Increased attention has been devoted to opportunistic pathogens, especially Legionella pneumophila, due to its growing importance as a portion of the waterborne disease burden in the United States. Infection occurs when a person inhales a mist containing Legionella bacteria. The top three uses for reclaimed water (cooling towers, spray irrigation, and toilet flushing) that generate aerosols were evaluated for Legionella health risks in reclaimed water using quantitative microbial risk assessment (QMRA). Risks are compared using data from nineteen United States reclaimed water utilities measured with culture-based methods, quantitative PCR (qPCR), and ethidium-monoazide-qPCR. Median toilet flushing annual infection risks exceeded 10^-4 considering multiple toilet types, while median clinical severity infection risks did not exceed this value. Sprinkler and cooling tower risks varied depending on meteorological conditions and operational characteristics such as drift eliminator performance. However, the greatest differences between risk scenarios were due to 1) the dose response model used (infection or clinical severity infection) 2) population at risk considered (residential or occupational) and 3) differences in laboratory analytical method. Theoretical setback distances necessary to achieve a median annual infection risk level of 10^-4 are proposed for spray irrigation and cooling towers. In both cooling tower and sprinkler cases, Legionella infection risks were non-trivial at potentially large setback distances, and indicate other simultaneous management practices could be needed to manage risks. The sensitivity analysis indicated that the most influential factors for variability in risks were the concentration of Legionella and aerosol partitioning and/or efficiency across all models, highlighting the importance of strategies to manage Legionella occurrence in reclaimed water.

Biofilms in shower hoses

Shower hoses offer an excellent bacterial growth environment in close proximity to a critical end-user exposure route within building drinking water plumbing. However, the health risks associated with and processes underlying the development of biofilms in shower hoses are poorly studied. In a global survey, biofilms from 78 shower hoses from 11 countries were characterized in terms of cell concentration (4.1 × 10⁴-5.8 × 10⁸ cells/cm²), metal accumulation (including iron, lead, and copper), and microbiome composition (including presence of potential opportunistic pathogens). In countries using disinfectant, biofilms had on average lower cell concentrations and diversity. Metal accumulation (up to 5 μg-Fe/cm², 75 ng-Pb/cm², and 460 ng-Cu/cm²) seemed to be partially responsible for discoloration in biofilms, and likely originated from other pipes upstream in the building. While some genera that may contain potential opportunistic pathogens (Legionella, detected in 21/78 shower hoses) were positively correlated with biofilm cell concentration, others (Mycobacterium, Pseudomonas) had surprisingly non-existent or negative correlations with biofilm cell concentrations. In a controlled study, 15 identical shower hoses were installed for the same time period in the same country, and both stagnant and flowing water samples were collected. Ecological theory of dispersal and selection helped to explain microbiome composition and diversity of different sample types. Shower hose age was related to metal accumulation but not biofilm cell concentration, while frequency of use appeared to influence biofilm cell concentration. This study shows that shower hose biofilms are clearly a critical element of building drinking water plumbing, and a potential target for building drinking water plumbing monitoring.