Legionellae in engineered systems and use of quantitative microbial risk assessment to predict exposure

A Diagnostic Chip for the Colorimetric Detection of Legionella pneumophila in Less than 3 h at the Point of Need

Legionella pneumophila has been pinpointed by the World Health Organization as the highest health burden of all waterborne pathogens in the European Union and is responsible for many disease outbreaks around the globe. Today, standard analysis methods (based on bacteria culturing onto agar plates) need several days (~12) in specialized analytical laboratories to yield results, not allowing for timely actions to prevent outbreaks. Over the last decades, great efforts have been made to develop more efficient waterborne pathogen diagnostics and faster analysis methods, requiring further advancement of microfluidics and sensors for simple, rapid, accurate, inexpensive, real-time, and on-site methods. Herein, a lab-on-a-chip device integrating sample preparation by accommodating bacteria capture, lysis, and DNA isothermal amplification with fast (less than 3 h) and highly sensitive, colorimetric end-point detection of L. pneumophila in water samples is presented, for use at the point of need. The method is based on the selective capture of viable bacteria on on-chip-immobilized and -lyophilized antibodies, lysis, the loop-mediated amplification (LAMP) of DNA, and end-point detection by a color change, observable by the naked eye and semiquantified by computational image analysis. Competitive advantages are demonstrated, such as low reagent consumption, portability and disposability, color change, storage at RT, and compliance with current legislation.

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.

EcoGenoRisk: Developing a computational ecological risk assessment tool for synthetic biology

The expanding field of synthetic biology (synbio) supports new opportunities in the design of targeted bioproducts or modified microorganisms. However, this rapid development of synbio products raises concerns surrounding the potential risks of modified microorganisms contaminating unintended environments. These potential invasion risks require new bioinformatic tools to inform the design phase. EcoGenoRisk is a newly constructed computational risk assessment tool for invasiveness that aims to predict where synbio microorganisms may establish a population by screening for habitats of genetically similar microorganisms. The first module of the tool identifies genetically similar microorganisms and potential ecological relationships such as competition, mutualism, and inhibition. In total, 520 archaeal and 32,828 bacterial complete assembly genomes were analyzed to test the specificity and accuracy of the tool as well as to characterize the enzymatic profiles of different taxonomic lineages. Additionally, ecological relationships were analyzed to determine which would result in the greatest potential overlap between shared functional profiles. Notably, competition displayed the significantly highest overlap of shared functions between compared genomes. Overall, EcoGenoRisk is a flexible software pipeline that assists environmental risk assessors to query large databases of known microorganisms and prioritize follow-up bench scale studies.

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.

Charting the landscape of the environmental exposome

The exposome depicts the total exposures in the lifetime of an organism. Human exposome comprises exposures from environmental and humanistic sources. Biological, chemical, and physical environmental exposures pose potential health threats, especially to susceptible populations. Although still in its nascent stage, we are beginning to recognize the vast and dynamic nature of the exposome. In this review, we systematically summarize the biological and chemical environmental exposomes in three broad environmental matrices-air, soil, and water; each contains several distinct subcategories, along with a brief introduction to the physical exposome. Disease-related environmental exposures are highlighted, and humans are also a major source of disease-related biological exposures. We further discuss the interactions between biological, chemical, and physical exposomes. Finally, we propose a list of outstanding challenges under the exposome research framework that need to be addressed to move the field forward. Taken together, we present a detailed landscape of environmental exposome to prime researchers to join this exciting new field.

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.

Legionella pneumophila Cas2 Promotes the Expression of Small Heat Shock Protein C2 That Is Required for Thermal Tolerance and Optimal Intracellular Infection

Previously, we demonstrated that Cas2 encoded within the CRISPR-Cas locus of Legionella pneumophila strain 130b promotes the ability of the Legionella pathogen to infect amoebal hosts. Given that L. pneumophila Cas2 has RNase activity, we posited that the cytoplasmic protein is regulating the expression of another Legionella gene(s) that fosters intracellular infection. Proteomics revealed 10 proteins at diminished levels in the cas2 mutant, and reverse transcription-quantitative (qRT-PCR) confirmed the reduced expression of a gene encoding putative small heat shock protein C2 (HspC2), among several others. As predicted, the gene was expressed more highly at 37°C to 50°C than that at 30°C, and an hspC2 mutant, but not its complemented derivative, displayed ~100-fold reduced CFU following heat shock at 55°C. Compatible with the effect of Cas2 on hspC2 expression, strains lacking Cas2 also had impaired thermal tolerance. The hspC2 mutant, like the cas2 mutant before it, was greatly impaired for infection of Acanthamoeba castellanii, a frequent host for legionellae in waters. HspC2 and Cas2 were not required for entry into these host cells but promoted the replicative phase of intracellular infection. Finally, the hspC2 mutant exhibited an additional defect during the infection of macrophages, which are the primary host for legionellae during lung infection. In summary, hspC2 is upregulated by the presence of Cas2, and HspC2 uniquely promotes both L. pneumophila extracellular survival at high temperatures and infection of amoebal and human host cells. To our knowledge, these findings also represent the first genetic proof linking Cas2 to thermotolerance, expanding the repertoire of noncanonical functions associated with CRISPR-Cas proteins.

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.

New immunomagnetic separation method to analyze risk factors for Legionella colonization in health care centres

BACKGROUND

It's pivotal to control the presence of legionella in sanitary structures. So, it's important to determine the risk factors associated with Legionella colonization in health care centres. In recent years that is why new diagnostic techniques have been developed.

OBJECTIVE

To evaluate risks factors for Legionella colonization using a novel and more sensitive Legionella positivity index.

METHODS

A total of 204 one-litre water samples (102 cold water samples and 102 hot water samples), were collected from 68 different sampling sites of the hospital water system and tested for Legionella spp. by two laboratories using culture, polymerase chain reaction and a method based on immunomagnetic separation (IMS). A Legionella positivity index was defined to evaluate Legionella colonization and associated risk factors in the 68 water samples sites. We performed bivariate analyses and then logistic regression analysis with adjustment of potentially confounding variables. We compared the performance of culture and IMS methods using this index as a new gold standard to determine if rapid IMS method is an acceptable alternative to the use of slower culture method.

RESULTS

Based on the new Legionella positivity index, no statistically significant differences were found neither between laboratories nor between methods (culture, IMS). Positivity was significantly correlated with ambulatory health assistance (p = 0.05) and frequency of use of the terminal points. The logistic regression model revealed that chlorine (p = 0.009) and the frequency of use of the terminal points (p = 0.001) are predictors of Legionella colonization. Regarding this index, the IMS method proved more sensitive (69%) than culture method (65.4%) in hot water samples.

SIGNIFICANCE

We showed that the frequency of use of terminal points should be considered when examining environmental Legionella colonization, which can be better evaluated using the provided Legionella positivity index. This study has implications for the prevention of Legionnaires' disease in hospital settings.

Hot water plumbing in residences and office buildings have distinctive risk of Legionella pneumophila contamination

AIM

To observe how Legionella pneumophila, the causative agent for legionellosis, can transmit through the hot water plumbing of residences and office buildings.

METHOD AND RESULTS

Using qPCR, L. pneumophila and L. pneumophila Serogroup (Sg)1 were measured in hot water samples collected from 100 structures, consisting of 70 residences and 30 office buildings. The hot water samples collected from office buildings had a higher L. pneumophila detection frequency of 53% (16/30) than residences, with a 103 GU/L (median) concentration. An office building's age was not a statistically significant predictor of contamination, but its area (>100,000 sq. ft.) was, P = <0.001. Hot water samples collected at residences had a lower L. pneumophila detection frequency of 36% (25/70) than office buildings, with a 100 GU/L (median) concentration. A residence's age was a significant predictor of contamination, P = 0.009, but not its area. The water's secondary disinfectant type did not affect L. pneumophila detection frequency nor its concentration in residences, but the secondary disinfectant type did affect results in office buildings. Legionella pneumophila's highest detection frequencies were in samples collected in March-August for office buildings and in June-November for residences.

CONCLUSION

This study revealed that the built environment influences L. pneumophila transport and fate. Residential plumbing could be a potential "conduit" for L. pneumophila exposure from a source upstream of the hot water environment. Both old and newly built office buildings had an equal probability of L. pneumophila contamination. Legionella-related remediation efforts in office buildings (that contain commercial functions only) might not significantly improve a community's public health.

Influence of Metal Concentration and Plumbing Materials on Legionella Contamination

Legionella colonization of water supply pipes is a significant public health problem. The objective of this work was to evaluate Legionella colonization in hotel hot water systems and to investigate the relationship between metal concentrations, piping materials (galvanized iron pipes and plastic pipes), and Legionella proliferation. Concentrations of calcium and magnesium ions and the presence of Legionella pneumophila were determined in a total of 108 water samples from the hot water systems of four hotels in Split-Dalmatia County over a 12-month period, and additional data on piping materials were collected. L. pneumophila was isolated in 23.1% of all samples-in 28.8% (15/52) of water samples from galvanized iron pipes and in 17.8% (10/56) of samples from plastic pipes. L. pneumophila serogroups 2-14 were isolated from all samples. This study found higher prevalence of L. pneumophila at higher concentrations of Ca and Mg ions (except for Mg and plastic pipes). The metal parts of the water supply may be important factors in Legionella contamination due to the possibility of lime scale or roughness of the pipes. Higher Ca and Mg ion concentrations increased the risk of Legionella colonization.

Chlorine decay and disinfection by-products formation during chlorination of biofilms formed with simulated drinking water containing corrosion inhibitors

Corrosion inhibitors used to reduce pipe corrosion can alter the physical structure and biochemical components of the biofilm in premise plumbing systems. We studied the effects of corrosion inhibitors on chlorine decay and associated disinfection by-products (DBPs) formation by biofilms grown with simulated drinking water amended with silicate, phosphate, and the phosphate blends. Experiments were conducted with either intact biofilms or biofilm materials dispersed in solution during sonication (referred to as biomass). While there was no significant difference in chlorine decay among biomass from different biofilms, biomass from the phosphate blend biofilm showed the lowest trihalomethane (THMs) and haloacetic acids (HAAs) formation. The chlorine decay rate constants from the biofilm experiment were ranked as: phosphate blends > phosphate ≈ groundwater (GW) > silicate. The kinetics of chlorine decay and formation of DBPs were successfully described by pseudo-first-order kinetics. These fitting parameters were used to predict the DBPs formation in a realistic premise plumbing system. The results showed that biofilm-derived THMs and HAAs increased with increasing chlorine concentration, while THMs and HAAs first increased and then stabilized to a maximum with increasing biofilm total organic carbon (TOC) concentration. In general, the biofilms grown with phosphate-based corrosion inhibitors resulted in lower DBPs formation yield but higher bacterial release, which could potentially increase the risk of user exposure to opportunistic pathogens in drinking water. The silicate biofilms showed the largest yield coefficient of DBPs formation but had the least biomass and lower bacterial release.

Risk Exposure to Legionella pneumophila during Showering: The Difference between a Classical and a Water Saving Shower System

The increase in legionellosis incidence in the general population in recent years calls for a better characterization of the sources of infection, such as showering. Water-efficient shower systems that use water-atomizing technology have been shown to emit slightly more inhalable particles in the range of bacterial sizes than the traditional systems; however, the actual rate of bacterial emission remains poorly documented. The aim of this study was to assess the aerosolisation rate of the opportunistic water pathogen Legionella pneumophila during showering with one shower system representative of each technology. To achieve this objective, we performed controlled experiments inside a glove box and determined the emitted dose and viability of airborne Legionella. The bioaerosols were sampled with a Coriolis^® Delta air sampler and the total number of viable (cultivable and noncultivable) Legionella was determined by flow cytometry and culture. We found that the rate of viable and cultivable Legionella aerosolized from the water jet was similar between the two showerheads: the viable fraction represents 0.02% of the overall bacteria present in water, while the cultivable fraction corresponds to only 0.0005%. The two showerhead models emitted a similar ratio of airborne Legionella viable and cultivable per volume of water used. Therefore, the risk of exposure to Legionella is not expected to increase significantly with the new generation of water-efficient showerheads.

Differences in UV-C LED Inactivation of Legionella pneumophila Serogroups in Drinking Water

Legionella pneumophila (Lp) is an opportunistic pathogen that causes respiratory infections primarily through inhalation of contaminated aerosols. Lp can colonize premise plumbing systems due to favorable growth conditions (e.g., lower disinfectant residual, stagnation, warm temperatures). UV-C light-emitting diodes (UV-C LEDs) are an emerging water treatment technology and have been shown to effectively inactivate waterborne pathogens. In this study, the inactivation of four Lp strains (three clinical sg1, 4, and 6; and one sg1 drinking water (DW) isolate) was evaluated using a UV-C LED collimated beam at three wavelengths (255, 265, and 280 nm) and six fluence rates (0.5–34 mJ/cm²). Exposure to 255 nm resulted in higher log reductions at the lower fluences compared to exposures at 265 and 280 nm. Efficacy testing was also performed using a UV-C LED point-of-entry (POE) flow-through device. Based on the log inactivation curves, at 255 nm, the sg4 and sg6 clinical isolates were more susceptible to inactivation compared to the two sg1 isolates. However, at 265 and 280 nm, the sg1 and sg4 clinical isolates were more resistant to inactivation compared to the sg6 clinical and sg1 DW isolates. Differential log reductions were also observed using the POE device. Results indicate that although UV-C LED disinfection is effective, variations in Lp inactivation, wavelengths, and technology applications should be considered, especially when targeting specific isolates within premise plumbing systems.

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).

Cooccurrence of Five Pathogenic Legionella spp. and Two Free-Living Amoebae Species in a Complete Drinking Water System and Cooling Towers

Pathogenic Legionella species grow optimally inside free-living amoebae to concentrations that increase risks to those who are exposed. The aim of this study was to screen a complete drinking water system and cooling towers for the occurrence of Acanthamoeba spp. and Naegleria fowleri and their cooccurrence with Legionella pneumophila, Legionella anisa, Legionella micdadei, Legionella bozemanii, and Legionella longbeachae. A total of 42 large-volume water samples, including 12 from the reservoir (water source), 24 from two buildings (influents to the buildings and exposure sites (taps)), and six cooling towers were collected and analyzed using droplet digital PCR (ddPCR). N. fowleri cooccurred with L. micdadei in 76 (32/42) of the water samples. In the building water system, the concentrations of N. fowleri and L. micdadei ranged from 1.5 to 1.6 Log₁₀ gene copies (GC)/100 mL, but the concentrations of species increased in the cooling towers. The data obtained in this study illustrate the ecology of pathogenic Legionella species in taps and cooling towers. Investigating Legionella’s ecology in drinking and industrial waters will hopefully lead to better control of these pathogenic species in drinking water supply systems and cooling towers.

Legionella and other opportunistic pathogens in full-scale chloraminated municipal drinking water distribution systems

Water-based opportunistic pathogens (OPs) are a leading cause of drinking-water-related disease outbreaks, especially in developed countries such as the United States (US). Physicochemical water quality parameters, especially disinfectant residuals, control the (re)growth, presence, colonization, and concentrations of OPs in drinking water distribution systems (DWDSs), while the relationship between OPs and those parameters remain unclear. This study aimed to quantify how physicochemical parameters, mainly monochloramine residual concentration, hydraulic residence time (HRT), and seasonality, affected the occurrence and concentrations of four common OPs (Legionella, Mycobacterium, Pseudomonas, and Vermamoeba vermiformis) in four full-scale DWDSs in the US. Legionella as a dominant OP occurred in 93.8% of the 64 sampling events and had a mean density of 4.27 × 105 genome copies per liter. Legionella positively correlated with Mycobacterium, Pseudomonas, and total bacteria. Multiple regression with data from the four DWDSs showed that Legionella had significant correlations with total chlorine residual level, free ammonia concentration, and trihalomethane concentration. Therefore, Legionella is a promising indicator of water-based OPs, reflecting microbial water quality in chloraminated DWDSs. The OP concentrations had strong seasonal variations and peaked in winter and/or spring possibly because of reduced water usage (i.e., increased water stagnation or HRT) during cold seasons. The OP concentrations generally increased with HRT presumably because of disinfectant residual decay, indicating the importance of well-maintaining disinfectant residuals in DWDSs for OP control. The concentrations of Mycobacterium, Pseudomonas, and V. vermiformis were significantly associated with total chlorine residual concentration, free ammonia concentration, and pH and trihalomethane concentration, respectively. Overall, this study demonstrates how the significant spatiotemporal variations of OP concentrations in chloraminated DWDSs correlated with critical physicochemical water quality parameters such as disinfectant residual levels. This work also indicates that Legionella is a promising indicator of OPs and microbial water quality in chloraminated DWDSs.

Environmental surveillance of Legionella pneumophila in hot water systems of hotels in Morocco

OBJECTIVE

Environmental monitoring of Legionella in hot water systems of hotels in Morocco was performed during the period from January 2016 to April 2018. A total of 149 water samples from 118 different hotels were analyzed.

METHODS

A total of 149 water samples from 118 different hotels were analyzed. Possible risk factors were prospectively recorded, and data were analyzed in connection with building and plumbing systems characteristics. Data about building and risk factors were collected through a questionnaire survey.

RESULTS

Out of the 149 samples, 77(51.7%) were positive for L. pneumophila. Serological typing of the isolates revealed that 54 (70.1%) are L. pneumophila serogroup 2-15 and 23 (29.9%) are L. pneumophila serogroup 1. 56.8% of all buildings were colonized by L. pneumophila. Counts were over 1,000 CFU/L in 44%. Contamination was strongly correlated with temperature in the circulation, the age of the premise plumbing and the size of the building.

CONCLUSIONS

The results showed a relevant exposure to L. pneumophila in the community and the identified risk factors can serve as indicators for risk assessment and relevant actions.

Validation of the Legionella pneumophila SG1 DETECT Kit for Quantification of Legionella pneumophila Serogroup 1 Bacteria in Potable Waters, Process Waters, and Surface Waters: AOAC Performance Tested MethodSM 052002

The L.p.SG1 DETECT Kit is a rapid, quantitative method for the detection and enumeration of Legionella pneumophila serogroup 1 (L.p. SG1) bacteria from different water matrixes. The method is based on a combination of immunomagnetic separation (IMS) and flow cytometric (FCM) quantification. To this end, the method employs magnetic particles conjugated to anti-L.p. SG1 antibodies for the IMS of the target bacteria from environmental matrices and fluorescently labeled anti-L.p. SG1 antibodies for subsequent quantification by FCM. The IMS can be performed either manually with a magnetic rack (rqmicro.MIMS) or automated with the rqmicro.STREAM sample preparation instrument. Compared to the reference method ISO 11731:2017, which is based on culturing and enumeration of colony forming units (CFU) on agar plates, and can take up to 10 days until results are available, analysis with the L.p. SG1 DETECT Kit is culture-independent and delivers results within 2 h. This Performance Tested Method validation study demonstrates a robust method with recoveries exceeding 69%, inclusivity of 100%, exclusivity of 97.2%, and a shelf life of at least 6 months at 4°C or 40 days at 25°C. The Limit of Detection (LOD) was determined at 21 CFU/L and the Limit of Quantification (LOQ) at 80 CFU/L for potable water using the rqmicro.STREAM. The matrix study across three different types of water matrixes (potable, surface, and industrial process water), demonstrates superior repeatability and reproducibility, as well as equivalent or even superior detection of L.p. SG1 bacteria compared to the standard ISO 11731 method.

Legionella and Biofilms-Integrated Surveillance to Bridge Science and Real-Field Demands

Legionella is responsible for the life-threatening pneumonia commonly known as Legionnaires’ disease or legionellosis. Legionellosis is known to be preventable if proper measures are put into practice. Despite the efforts to improve preventive approaches, Legionella control remains one of the most challenging issues in the water treatment industry. Legionellosis incidence is on the rise and is expected to keep increasing as global challenges become a reality. This puts great emphasis on prevention, which must be grounded in strengthened Legionella management practices. Herein, an overview of field-based studies (the system as a test rig) is provided to unravel the common roots of research and the main contributions to Legionella’s understanding. The perpetuation of a water-focused monitoring approach and the importance of protozoa and biofilms will then be discussed as bottom-line questions for reliable Legionella real-field surveillance. Finally, an integrated monitoring model is proposed to study and control Legionella in water systems by combining discrete and continuous information about water and biofilm. Although the successful implementation of such a model requires a broader discussion across the scientific community and practitioners, this might be a starting point to build more consistent Legionella management strategies that can effectively mitigate legionellosis risks by reinforcing a pro-active Legionella prevention philosophy.

Local Adaptation of Legionella pneumophila within a Hospital Hot Water System Increases Tolerance to Copper

In large-building water systems, Legionella pneumophila is exposed to common environmental stressors such as copper. The aim of this study was to evaluate the susceptibility to copper of L. pneumophila isolates recovered from various sites: two clinical and seven environmental isolates from hot water system biofilm and water and from cooling tower water. After a 1-week acclimation in simulated drinking water, strains were exposed to various copper concentrations (0.8 to 5 mg/liter) for over 672 h. Complete loss of culturability was observed for three isolates following copper exposure to 5 mg/liter for 672 h. Two sequence type 1427 (ST1427)-like isolates were highly sensitive to copper, while the other two, isolated from biofilm samples, maintained higher culturability. The expression of the copper resistance gene copA evaluated by reverse transcription-quantitative PCR (RT-qPCR) was significantly higher for the biofilm isolates. All four ST1427-like isolates were recovered from the same water system during an outbreak. Whole-genome sequencing results confirmed that the four isolates are very close phylogenetically, differing by only 29 single nucleotide polymorphisms, suggesting in situ adaptation to microenvironmental conditions, possibly due to epigenetic regulation. These results indicate that the immediate environment within a building water distribution system influences the tolerance of L. pneumophila to copper. Increased contact of L. pneumophila biofilm strains with copper piping or copper alloys in the heat exchanger might lead to local adaptation. The phenotypic differences observed between water and biofilm isolates from the hot water system of a health care facility warrants further investigation to assess the relevance of evaluating disinfection performances based on water sampling alone.IMPORTANCELegionella pneumophila is a pathogen indigenous to natural and large building water systems in the bulk and the biofilm phases. The immediate environment within a system can impact the tolerance of L. pneumophila to environmental stressors, including copper. In health care facilities, copper levels in water can vary, depending on water quality, plumbing materials, and age. This study evaluated the impact of the isolation site (water versus biofilm, hot water system versus cooling tower) within building water systems. Closely related strains isolated from a health care facility hot water system exhibited variable tolerance to copper stress, shown by differential expression of copA, with biofilm isolates displaying highest expression and tolerance. Relying on the detection of L. pneumophila in water samples following exposure to environmental stressors such as copper may underestimate the prevalence of L. pneumophila, leading to inappropriate risk management strategies and increasing the risk of exposure for vulnerable patients.

Occurrence and quantification of culturable and viable but non-culturable (VBNC) pathogens in biofilm on different pipes from a metropolitan drinking water distribution system

Waterborne pathogens have been found in biofilms grown in drinking water distribution system (DWDS). However, there is a lack of quantitative study on the culturability of pathogens in biofilms from metropolitan DWDS. In this study, we quantified culturable and viable but non-culturable (VBNC) Escherichia coli, Salmonella enterica, Pseudomonas aeruginosa and Vibrio cholerae in biofilms collected from five kinds of pipes (galvanized steel pipe, steel pipe, stainless steel clad pipe, ductile cast iron pipe and polyethylene pipe) and associated drinking water at an actual chlorinated DWDS in use from China. The results of these comprehensive analyses revealed that pipe material is a significant factor influencing the culturability of pathogen and microbial communities. Network analysis of the culturable pathogens and 16S rRNA gene inferred potential interactions between microbiome and culturability of pathogens. Although the water quality met the Chinese national standard of drinking water, however, VBNC pathogens were detected in both biofilms and water from the DWDS. This investigation suggests that stainless steel clad pipe (SSCP) was a better choice for pathogen control compared with other metal pipes. To our knowledge, this is the first study on culturable and VBNC pathogens in biofilms of different pipe materials in metropolitan DWDS.

Developing Bayesian networks in managing the risk of Legionella colonisation of groundwater aeration systems

An Australian water utility has developed a Legionella High Level Risk Assessment (LHLRA) which provides a semi-qualitative assessment of the risk of Legionella proliferation and human exposure in engineered water systems using a combination of empirical observation and expert knowledge. Expanding on this LHLRA, we propose two iterative Bayesian network (BN) models to reduce uncertainty and allow for a probabilistic representation of the mechanistic interaction of the variables, built using data from 25 groundwater treatment plants. The risk of Legionella exposure in groundwater aeration units was quantified as a function of five critical areas including hydraulic conditions, nutrient availability and growth, water quality, system design (and maintenance), and location and access. First, the mechanistic relationship of the variables was conceptually mapped into a fishbone diagram, parameterised deterministically using an expert elicited weighted scoring system and translated into BN. The "sensitivity to findings" analysis of the BN indicated that system design was the most influential variable while elemental accumulation thresholds were the least influential variable for Legionella exposure. The diagnostic inference was used in high and low-risk scenarios to demonstrate the capabilities of the BNs to examine probable causes for diverse conditions. Subsequently, the causal relationship of Legionella growth and human exposure were improved through a conceptual bowtie representation. Finally, an improved model developed the predictors of Legionella growth and the risk of human exposure through the interaction of operational, water quality monitoring, operational parameters, and asset conditions. The use of BNs modelling based on risk estimation and improved functional decision outputs offer a complementary and more transparent alternative approach to quantitative analysis of uncertainties than the current LHLRA.

Unravelling the importance of the eukaryotic and bacterial communities and their relationship with Legionella spp. ecology in cooling towers: a complex network

BACKGROUND

Cooling towers are a major source of large community-associated outbreaks of Legionnaires' disease, a severe pneumonia. This disease is contracted when inhaling aerosols that are contaminated with bacteria from the genus Legionella, most importantly Legionella pneumophila. How cooling towers support the growth of this bacterium is still not well understood. As Legionella species are intracellular parasites of protozoa, it is assumed that protozoan community in cooling towers play an important role in Legionella ecology and outbreaks. However, the exact mechanism of how the eukaryotic community contributes to Legionella ecology is still unclear. Therefore, we used 18S rRNA gene amplicon sequencing to characterize the eukaryotic communities of 18 different cooling towers. The data from the eukaryotic community was then analysed with the bacterial community of the same towers in order to understand how each community could affect Legionella spp. ecology in cooling towers.

RESULTS

We identified several microbial groups in the cooling tower ecosystem associated with Legionella spp. that suggest the presence of a microbial loop in these systems. Dissolved organic carbon was shown to be a major factor in shaping the eukaryotic community and may be an important factor for Legionella ecology. Network analysis, based on co-occurrence, revealed that Legionella was correlated with a number of different organisms. Out of these, the bacterial genus Brevundimonas and the ciliate class Oligohymenophorea were shown, through in vitro experiments, to stimulate the growth of L. pneumophila through direct and indirect mechanisms.

CONCLUSION

Our results suggest that Legionella ecology depends on the host community, including ciliates and on several groups of organisms that contribute to its survival and growth in the cooling tower ecosystem. These findings further support the idea that some cooling tower microbiomes may promote the survival and growth of Legionella better than others. Video Abstract.

Legionella Diversity and Spatiotemporal Variation in The Occurrence of Opportunistic Pathogens within a Large Building Water System

Understanding Legionella survival mechanisms within building water systems (BWSs) is challenging due to varying engineering, operational, and water quality characteristics unique to each system. This study aimed to evaluate Legionella, mycobacteria, and free-living amoebae occurrence within a BWS over 18-28 months at six locations differing in plumbing material and potable water age, quality, and usage. A total of 114 bulk water and 57 biofilm samples were analyzed. Legionella culturability fluctuated seasonally with most culture-positive samples being collected during the winter compared to the spring, summer, and fall months. Positive and negative correlations between Legionella and L. pneumophila occurrence and other physiochemical and microbial water quality parameters varied between location and sample types. Whole genome sequencing of 19 presumptive Legionella isolates, from four locations across three time points, identified nine isolates as L. pneumophila serogroup (sg) 1 sequence-type (ST) 1; three as L. pneumophila sg5 ST1950 and ST2037; six as L. feeleii; and one as Ochrobactrum. Results showed the presence of a diverse Legionella population with consistent and sporadic occurrence at four and two locations, respectively. Viewed collectively with similar studies, this information will enable a better understanding of the engineering, operational, and water quality parameters supporting Legionella growth within BWSs.

Prevention of nosocomial legionellosis by best water management: comparison of three decontamination methods

BACKGROUND

Since 2000, the National Health System has adopted international guidelines for assessing Legionella spp. in hospital water systems. The control of water contamination by Legionella spp. is still a matter of research concerning the most effective method in preventing nosocomial infections.

AIM

To compare three different decontamination methods by monitoring colony-forming unit count and number of hospital-acquired legionellosis cases. A secondary objective was to evaluate the long-term effects of the preventive measures on the water pipes.

METHODS

A protocol was developed for the selection of high-risk sampling sites and for the testing of three disinfection methods over the course of 19 years: hyperchlorination and thermal shock (period A, 2000-2005); copper-silver ionization (period B, 2006-2010); and integration of pre-filtering, filtering, pipe-protecting products, and remote control with chlorine dioxide (ClO₂) (period C, 2011-2018).

FINDINGS

The use of shock disinfection and hyperchlorination led to a decrease in contamination level immediately after the procedure, but then it rose again to the previous level in two months. Both copper-silver ionization and ClO₂ disinfection showed a stable and durable decrease in contamination level. Throughout these three phases, six cases of Legionella spp. occurred during period A, six cases during period B, and three cases during period C. With regard to the damage of water pipes, effective copper-silver levels caused corrosion and calcification in water pipes.

CONCLUSION

Both copper-silver ionization and ClO₂ properly controlled Legionella spp. contamination. ClO₂ significantly reduced the number of positive sites (P < 0.001) without damaging the pipelines.

Impact of temperature on Legionella pneumophila, its protozoan host cells, and the microbial diversity of the biofilm community of a pilot cooling tower

Legionella pneumophila is a waterborne bacterium known for causing Legionnaires' Disease, a severe pneumonia. Cooling towers are a major source of outbreaks, since they provide ideal conditions for L. pneumophila growth and produce aerosols. In such systems, L. pneumophila typically grow inside protozoan hosts. Several abiotic factors such as water temperature, pipe material and disinfection regime affect the colonization of cooling towers by L. pneumophila. The local physical and biological factors promoting the growth of L. pneumophila in water systems and its spatial distribution are not well understood. Therefore, we built a lab-scale cooling tower to study the dynamics of L. pneumophila colonization in relationship to the resident microbiota and spatial distribution. The pilot was filled with water from an operating cooling tower harboring low levels of L. pneumophila. It was seeded with Vermamoeba vermiformis, a natural host of L. pneumophila, and then inoculated with L. pneumophila. After 92 days of operation, the pilot was disassembled, the water was collected, and biofilm was extracted from the pipes. The microbiome was studied using 16S rRNA and 18S rRNA genes amplicon sequencing. The communities of the water and of the biofilm were highly dissimilar. The relative abundance of Legionella in water samples reached up to 11% whereas abundance in the biofilm was extremely low (≤0.5%). In contrast, the host cells were mainly present in the biofilm. This suggests that L. pneumophila grows in host cells associated with biofilm and is then released back into the water following host cell lysis. In addition, water temperature shaped the bacterial and eukaryotic community of the biofilm, indicating that different parts of the systems may have different effects on Legionella growth.

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.

Isolation of Legionella pneumophila by Co-culture with Local Ameba, Canada

Legionellosis was diagnosed in an immunocompromised 3-year-old girl in Canada. We traced the source of the bacterium through co-culture with an ameba collected from a hot tub in her home. We identified Legionella pneumophila serogroup 6, sequence type 185, and used whole-genome sequencing to confirm the environmental and clinical isolates were of common origin.

Reverse QMRA as a Decision Support Tool: Setting Acceptable Concentration Limits for Pseudomonas aeruginosa and Naegleria fowleri

Opportunistic premise plumbing pathogens such as Pseudomonas aeruginosa and Naegleria fowleri are a growing concern in building water systems because of their potential risks to human health. The aim of this study was to determine the critical concentrations of P. aeruginosa and N. fowleri in water that are associated with meaningful public health risks. To determine these concentrations, a reverse quantitative microbial risk assessment (QMRA) was conducted. Environmental concentrations of P. aeruginosa and N. fowleri corresponding to the risk target of one micro-disability-adjusted life year (DALY) per person per year and 10−4 annual risks of illness were calculated for several applicable exposure scenarios. To calculate the concentration of P. aeruginosa, cleaning contact lenses with potentially contaminated tap water in the absence of an appropriate cleaning solution was considered. For N. fowleri, two exposure scenarios, recreational exposure (swimming) and nasal cleansing (via the use of a neti pot™ or similar device) were considered. The highest critical concentration for P. aeruginosa was found to be 33 CFU/L with a 95% confidence interval of (2.0, 118) for the drop exposure scenario using the 10−4 annual risk target. For N. fowleri, based on the DALY approach, critical concentrations were 0.000030 N. fowleri/L for swimming and 0.00000060 N. fowleri/L for neti pot™ use scenario. Considering heat inactivation, the critical concentration limits for P. aeruginosa using the DALY approach and the 10−4 annual risk target approach were found to be 0.55 CFU/L and 55 CFU/L, respectively. For N. fowleri, the 10−4 annual risk target approach resulted in 0.022 N. fowleri/L and the DALY approach resulted in 0.00000064 N. fowleri/L for the neti pot™ scenario. For P. aeruginosa, N50 (the median infective dose) and alpha (α) contributed the most and contact rates the least to the variability and uncertainty of the estimates for all the scenarios. For N. fowleri, N50 and contact rates contributed the most and α the least to the variability and uncertainty to calculate the concentrations for all the scenarios. The QMRA framework implemented in this research can be used to incorporate more information regarding opportunistic pathogens to inform management decisions, and to prioritize the best interventions regarding estimated reduction in infections caused by opportunistic pathogens.

Viability and infectivity of viable but nonculturable Legionella pneumophila strains induced at high temperatures

Thermal disinfection is commonly used to prevent the proliferation of culturable Legionella in engineered water systems (EWS). In response to such stress, culturable Legionella populations can switch into a viable but nonculturable (VBNC) state. The importance of such VBNC Legionella cells is currently hotly debated. Here, we investigated the stress response patterns and transitions of the bacteria to the VBNC state at 55 °C, 60 °C and 70 °C on two L. pneumophila strains for >80 days using a combination of cell-based viability indicators. Complete loss of culturability at 55 °C, 60 °C and 70 °C occurred after 3-8 h, 60 min and <2 min, respectively. In contrast, L. pneumophila strains required 9 days at 55 °C, 8 h at 60 °C and 20 min at 70 °C to achieve a 2 log reduction in cells with intact membranes and high esterase activity; a 4 log reduction was achieved only after 150, 8-15 and 1-4 days, respectively. In parallel, the presence of diagnostic outer-membrane epitopes (OMEs) and changes in the infectivity patterns of the two strains towards amoebae and THP-1 cells were assessed. OMEs were more persistent than viability indicators, showing their potential as targets for VBNC Legionella detection. L. pneumophila strains infected amoebae and THP-1 cells for at least 85 days at 55 °C and 60 °C and for up to 8 days at 70 °C. However, they did so with reduced efficiency, requiring prolonged co-incubation times with the hosts and higher Legionella cell numbers in comparison to culturable cells. Consequently, infection of amoebae by thermally induced VBNC L. pneumophila with lowered virulence can be expected in EWS. Although the gold standard method cannot detect VBNC Legionella, it provides important information about the most virulent bacterial subpopulations. Our results indicate that a prolonged thermal regime ≥60 °C at the central parts of warm water systems is not only effective against culturable L. pneumophila but in the long run even against VBNC cells.

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.

Potable Water Reuse: What Are the Microbiological Risks?

PURPOSE OF REVIEW

With the increasing interest in recycling water for potable reuse purposes, it is important to understand the microbial risks associated with potable reuse. This review focuses on potable reuse systems that use high-level treatment and de facto reuse scenarios that include a quantifiable wastewater effluent component.

RECENT FINDINGS

In this article, we summarize the published human health studies related to potable reuse, including both epidemiology studies and quantitative microbial risk assessments (QMRA). Overall, there have been relatively few health-based studies evaluating the microbial risks associated with potable reuse. Several microbial risk assessments focused on risks associated with unplanned (or de facto) reuse, while others evaluated planned potable reuse, such as indirect potable reuse (IPR) or direct potable reuse (DPR). The reported QMRA-based risks for planned potable reuse varied substantially, indicating there is a need for risk assessors to use consistent input parameters and transparent assumptions, so that risk results are easily translated across studies. However, the current results overall indicate that predicted risks associated with planned potable reuse scenarios may be lower than those for de facto reuse scenarios. Overall, there is a clear need to carefully consider water treatment train choices when wastewater is a component of the drinking water supply (whether de facto, IPR, or DPR). More data from full-scale water treatment facilities would be helpful to quantify levels of viruses in raw sewage and reductions across unit treatment processes for both culturable and molecular detection methods.

Legionella pneumophila levels and sequence-type distribution in hospital hot water samples from faucets to connecting pipes

Recent studies have reported increased levels of Legionella pneumophila (Lp) at points of use compared to levels in primary and secondary components of hot water systems, suggesting possible selection by environmental conditions. In this study, concentrations of Lp in a hospital hot water system were evaluated by profile sampling, collecting successive water samples to determine the prevalence at the faucet (distal) and upstream piping before and after a system intervention to increase temperature. Lp strain diversity was compared between different points of use and different areas of the hot water system (i.e., tap, intermediate piping and main upflow piping). In total, 47 isolates were recovered from 32 positive hot water samples collected from designated taps, showers and recirculation loops; these isolates were subsequently analyzed by sequence-based typing (SBT). Lp levels were comparable between first draw (500 mL) and flushed (2 and 5 min) samples, whereas a decrease was observed in the amount of culturable cells (1 log). Two sequence types (STs) were identified throughout the system. ST378 (sg4/10) was present in 91% of samples, while ST154-like (sg1) was present in 41%; both STs were simultaneously recovered in 34% of samples. Isolated STs displayed comparable tolerance to copper (0.8-5 mg/L) and temperature (55 °C, 1 h) exposure. The ability to replicate within THP1 cells and Acanthamoeba castellanii was similar between the two STs and a comparative environmental outbreak strain. The low Lp diversity and the detection of both Lp sequence types in repeated subsequent samples collected from positive faucets in a hospital wing suggest a minimal impact of the distal conditions on strain selection for the sampled points, as well as a possible adaptation to stressors present in the system, leading to the predominance of a few strains.

Chlorine and Monochloramine Disinfection of Legionella pneumophila Colonizing Copper and Polyvinyl Chloride Drinking Water Biofilms

Building water systems promote the regrowth and survival of opportunistic pathogens, such as Legionella pneumophila, especially within biofilms, where most drinking water microbes reside. However, compared to their planktonic form, disinfection efficacy for the biofilm-associated forms of water-based pathogens is unclear. The aim of this study was to determine the effectiveness of free chlorine and monochloramine in the inactivation of biofilm-associated L. pneumophila strain Philadelphia-1 serogroup 1 (LpP1s1). Mature (1.5- to 2-year-old) drinking water biofilms were developed on copper (Cu) and polyvinyl chloride (PVC) slides within biofilm annular reactors, then colonized with LpP1s1 at approximately 4 log₁₀ CFU cm^-2 and exposed to 2 mg liter^-1 of free chlorine or monochloramine. Ct (disinfectant concentration × time, expressed as mg min liter^-1) inactivation values for 2-, 3-, and 4-log₁₀ reductions of planktonic and biofilm LpP1s1 were determined. For planktonic LpP1s1, free chlorine was more effective at inactivation than was monochloramine treatment, and for biofilm-associated LpP1s1, monochloramine was more effective on Cu biofilms while free chlorine was more effective on PVC biofilms. In contrast to monochloramine, free chlorine treatment of Cu and PVC biofilms, negatively impacted LpP1s1 16S rRNA gene transcript levels and may act synergistically with Cu surfaces to further reduce transcript levels. Moreover, LpP1s1 cells shed from biofilms into the bulk water were more resistant to disinfection than were prepared planktonic LpP1s1 cells. Results from this study indicate that biofilm association, disinfectant type, and substratum play an important role in the survival of Legionella pneumophila in building water systems.IMPORTANCE Microbial regrowth within building water systems are promoted by water stagnation, low disinfectant residual, high surface-to-volume ratio, amenable growth temperatures, and colonization of drinking water biofilms. Moreover, biofilms provide protection from environmental stresses, access to higher levels of nutrients, and opportunities for symbiotic interactions with other microbes. Disinfectant efficacy information is historically based on inactivation of pathogens in their planktonic, free-floating forms. However, due to the ecological importance of drinking water biofilms for pathogen survival, this study evaluated the efficacy of two common disinfectants, free chlorine and monochloramine, on Legionella pneumophila colonizing mature, drinking water biofilms established on copper and PVC surfaces. Results showed that inactivation was dependent on the disinfectant type and biofilm substratum. Overall, this, and other related research, will provide a better understanding of Legionella ecological stability and survival and aid policy makers in the management of exposure risks to water-based pathogens within building water systems.

Electrically heatable carbon nanotube point-of-use filters for effective separation and in-situ inactivation of Legionella pneumophila

Despite municipal chlorination and secondary disinfection, opportunistic waterborne pathogens (e.g., Legionella spp.) persist in public and private water distribution systems. As a potential source of healthcare-acquired infections, this warrants development of novel pathogen removal and inactivation systems. In this study, electrically heatable carbon nanotube (CNT) point-of-use (POU) filters have been designed to remove and inactivate Legionella pneumophila in water. The CNT/polymer composite membranes effectively removed Legionella (> 99.99%) (i.e., below detection limit) and were able to inactive them on the membrane surface at 100% efficiency within 60 s using ohmic heating at 20 V. The novel POU filters could be used as a final barrier to provide efficient rejection of pathogens and thereby simultaneously eliminate microorganisms in public and private water supplies.

New approach to environmental investigation of an explosive legionnaires´ disease outbreak in Spain: early identification of potential risk sources by rapid Legionella spp immunosensing technique

Background

An explosive outbreak of Legionnaires’ disease (LD) was identified on 11 December 2015 in Manzanares, Ciudad Real, Spain, and was declared closed by 03 February 2016. The number of declared cases was 593 with 277 confirmed cases so that it can be considered as one of the outbreaks with highest attack rate. This rate could be attributed to the ageing of the population, among others, in addition to various risk factors and habits, and the meteorological conditions (thermal inversion) maintained in this municipality at the time. The Public Health Services succeeded in breaking the bacterial transmission. Several facilities were early identified by microbiological analysis, including a cooling tower and a decorative fountain, as possible infectious sources. Rapid analytical techniques for rapid Legionella detection and the shutdown and preventative closure of positive installations have been considered key elements in the control of this outbreak.

Results

Rapid microbiological analysis helped to the early identification of potential risk sources in a Legionnaires´ disease outbreak, reducing decision-making processes according to the actual needs of the intervention in public health and shortening the exposure of the population.

Conclusions

Protocolized and immediate intervention in an outbreak is a crucial issue to reduce their effects on public health. For this, identification and control of the suspicious sources able to disseminate the bacteria and cause the illness is required. Rapid analytical techniques like immunomagnetic separation (IMS) method based on the whole bacterial cell detection are shown as excellent tools to investigate all the potential sources of risk.

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.

Legionella confirmation in cooling tower water. Comparison of culture, real-time PCR and next generation sequencing

Objectives:

To investigate the presence of Legionella spp in cooling tower water. Legionella proliferation in cooling tower water has serious public health implications as it can be transmitted to humans via aerosols and cause Legionnaires’ disease.

Methods:

Samples of cooling tower water were collected from King Fahd Hospital of the University (KFHU) (Imam Abdulrahman Bin Faisal University, 2015/2016). The water samples were analyzed by a standard Legionella culture method, real-time polymerase chain reaction (RT-PCR), and 16S rRNA next-generation sequencing. In addition, the bacterial community composition was evaluated.

Results:

All samples were negative by conventional Legionella culture. In contrast, all water samples yielded positive results by real-time PCR (10⁵ to 10⁶ GU/L). The results of 16S rRNA next generation sequencing showed high similarity and reproducibility among the water samples. The majority of sequences were Alpha-, Beta-, and Gamma-proteobacteria, and Legionella was the predominant genus. The hydrogen-oxidizing gram-negative bacterium Hydrogenophaga was present at high abundance, indicating high metabolic activity. Sphingopyxis, which is known for its resistance to antimicrobials and as a pioneer in biofilm formation, was also detected.

Conclusion:

Our findings indicate that monitoring of Legionella in cooling tower water would be enhanced by use of both conventional culturing and molecular methods.

Quantitative Microbial Risk Assessment and Opportunist Waterborne Infections⁻Are There Too Many Gaps to Fill?

Quantitative microbial risk assessment (QMRA) is a relatively new approach in identifying health risks associated with the ubiquitous presence of pathogens and opportunists in the human environment. The methodology builds on experimental and meta-analytical data to identify measurable factors that contribute to, and can quantify, the likely extent of disease given a particular exposure. Early modelling was particularly focused on food-borne disease, and subsequently water-borne disease, with the emphasis focused on ingestion and its role in enteric disease. More recently, there has been a focus on translating these principles to opportunist waterborne infections (OWI) with primary focus on Legionella spp. Whereas dose and susceptibility are well documented via the ingestion route of exposure there is considerably less certainty regarding both factors when understanding Legionella spp. and other OWI. Many OWI can arise through numerous routes of transmission with greatly differing disease presentations. Routes of Legionella spp. infection do not include ingestion, but rather aspiration and inhalation of contaminated water are the routes of exposure. The susceptible population for OWI is a vulnerable sub-set of the population unlike those associated with enteric disease pathogens. These variabilities in dose, exposure and susceptibility call in to question whether QMRA can be a useful tool in managing risks associated with OWI. Consideration of Legionella spp. as a well-documented subject of research calls into question whether QMRA of OWI is likely to be a useful tool in developing risk management strategies.

Electrophoretic mobility of Legionella pneumophila serogroups 1 to 14

Legionella pneumophila (Lp) is ubiquitous in the aquatic environment and can persist within drinking water distribution systems (DWDS) enabling these systems to serve as a potential source of human infections. Bacterial surface charge, deduced from electrophoretic mobility (EPM), is a well-recognized contributor to microorganism mobility, adherence and interactions with their surrounding environment. In this study, the EPM of 32 Lp strains representing serogroup (sg) 1 to 14 were measured, in 9.15 mM KH2PO4 at pH 8, to understand cell surface properties that may influence their occurrence within DWDS. EPM measurements indicated the charge of Lp varied widely between serogroups with five distinct clusters, from least to most negatively charged: (i) sg1 to 3, 5, and 12; (ii) sg6, 8, and 10; (iii) sg9 and 13; (iv) sg7, 11, and 14; and (v) sg4. The EPM of sg1 and 4 strains were pH dependent; however, values were constant between pH 6 and 9, a range typical of drinking water, suggesting that EPM differences between Lp serogroups could impact their survival within DWDS. Understanding the ecological importance of Lp surface properties (e.g. in mobility, colonization, resistance to disinfectants, etc.) within DWDS would aid in mitigation of health risks associated with this water-based pathogen.

Diverse Legionella-Like Bacteria Associated with Testate Amoebae of the Genus Arcella (Arcellinida: Amoebozoa)

Diverse species of Legionella and Legionella-like amoebal pathogens (LLAPs) have been identified as intracellular bacteria in many amoeboid protists. There are, however, other amoeboid groups such as testate amoeba for which we know little about their potential to host such bacteria. In this study, we assessed the occurrence and diversity of Legionella spp. in cultures and environmental isolates of freshwater arcellinid testate amoebae species, Arcella hemispherica, Arcella intermedia, and Arcella vulgaris, via 16S rRNA gene sequence analyses and fluorescent in situ hybridization (FISH). Analysis of the 16S rRNA gene sequences indicated that A. hemispherica, A. intermedia, and A. vulgaris host Legionella-like bacteria with 94-98% identity to other Legionella spp. based on NCBI BLAST search. Phylogenetic analysis placed Legionella-like Arcella-associated bacteria (LLAB) in three different clusters within a tree containing all other members of Legionella and LLAPs. The intracellular localization of the Legionella within Arcella hosts was confirmed using FISH with a Legionella-specific probe. This study demonstrates that the host range of Legionella and Legionella-like bacteria in the Amoebozoa extends beyond members of "naked" amoebae species, with members of the testate amoebae potentially serving an ecological role in the dispersal, protection, and replication of Legionella spp. in natural environments.

Environmental Validation of Legionella Control in a VHA Facility Water System

OBJECTIVES We conducted this study to determine what sample volume, concentration, and limit of detection (LOD) are adequate for environmental validation of Legionella control. We also sought to determine whether time required to obtain culture results can be reduced compared to spread-plate culture method. We also assessed whether polymerase chain reaction (PCR) and in-field total heterotrophic aerobic bacteria (THAB) counts are reliable indicators of Legionella in water samples from buildings. DESIGN Comparative Legionella screening and diagnostics study for environmental validation of a healthcare building water system. SETTING Veterans Health Administration (VHA) facility water system in central Texas. METHODS We analyzed 50 water samples (26 hot, 24 cold) from 40 sinks and 10 showers using spread-plate cultures (International Standards Organization [ISO] 11731) on samples shipped overnight to the analytical lab. In-field, on-site cultures were obtained using the PVT (Phigenics Validation Test) culture dipslide-format sampler. A PCR assay for genus-level Legionella was performed on every sample. RESULTS No practical differences regardless of sample volume filtered were observed. Larger sample volumes yielded more detections of Legionella. No statistically significant differences at the 1 colony-forming unit (CFU)/mL or 10 CFU/mL LOD were observed. Approximately 75% less time was required when cultures were started in the field. The PCR results provided an early warning, which was confirmed by spread-plate cultures. The THAB results did not correlate with Legionella status. CONCLUSIONS For environmental validation at this facility, we confirmed that (1) 100 mL sample volumes were adequate, (2) 10× concentrations were adequate, (3) 10 CFU/mL LOD was adequate, (4) in-field cultures reliably reduced time to get results by 75%, (5) PCR provided a reliable early warning, and (6) THAB was not predictive of Legionella results. Infect Control Hosp Epidemiol 2018;39:259-266.

Opportunistic Pathogens and Microbial Communities and Their Associations with Sediment Physical Parameters in Drinking Water Storage Tank Sediments

The occurrence and densities of opportunistic pathogens (OPs), the microbial community structure, and their associations with sediment elements from eight water storage tanks in Ohio, West Virginia, and Texas were investigated. The elemental composition of sediments was measured through X-ray fluorescence (XRF) spectra. The occurrence and densities of OPs and amoeba hosts (i.e., Legionella spp. and L. pneumophila, Mycobacterium spp., P. aeruginosa, V. vermiformis, Acanthamoeba spp.) were determined using genus- or species-specific qPCR assays. Microbial community analysis was performed using next generation sequencing on the Illumina Miseq platform. Mycobacterium spp. were most frequently detected in the sediments and water samples (88% and 88%), followed by Legionella spp. (50% and 50%), Acanthamoeba spp. (63% and 13%), V. vermiformis (50% and 25%), and P. aeruginosa (0 and 50%) by qPCR method. Comamonadaceae (22.8%), Sphingomonadaceae (10.3%), and Oxalobacteraceae (10.1%) were the most dominant families by sequencing method. Microbial communities in water samples were mostly separated with those in sediment samples, suggesting differences of communities between two matrices even in the same location. There were associations of OPs with microbial communities. Both OPs and microbial community structures were positively associated with some elements (Al and K) in sediments mainly from pipe material corrosions. Opportunistic pathogens presented in both water and sediments, and the latter could act as a reservoir of microbial contamination. There appears to be an association between potential opportunistic pathogens and microbial community structures. These microbial communities may be influenced by constituents within storage tank sediments. The results imply that compositions of microbial community and elements may influence and indicate microbial water quality and pipeline corrosion, and that these constituents may be important for optimal storage tank management within a distribution system.

Experimental human-like model to assess the part of viable Legionella reaching the thoracic region after nebulization

The incidence of Legionnaires’ disease (LD) in European countries and the USA has been constantly increasing since 1998. Infection of humans occurs through aerosol inhalation. To bridge the existing gap between the concentration of Legionella in a water network and the deposition of bacteria within the thoracic region (assessment of the number of viable Legionella), we validated a model mimicking realistic exposure through the use of (i) recent technology for aerosol generation and (ii) a 3D replicate of the human upper respiratory tract. The model’s sensitivity was determined by monitoring the deposition of (i) aerosolized water and Tc^99m radio-aerosol as controls, and (ii) bioaerosols generated from both Escherichia coli and Legionella pneumophila sg 1 suspensions. The numbers of viable Legionella prior to and after nebulization were provided by culture, flow cytometry and qPCR. This study was designed to obtain more realistic data on aerosol inhalation (vs. animal experimentation) and deposition at the thoracic region in the context of LD. Upon nebulization, 40% and 48% of the initial Legionella inoculum was made of cultivable and non-cultivable cells, respectively; 0.7% of both populations reached the filter holder mimicking the thoracic region in this setup. These results are in agreement with experimental data based on quantitative microbial risk assessment methods and bring new methods that may be useful for preventing LD.

Quantification of viable and non-viable Legionella spp. by heterogeneous asymmetric recombinase polymerase amplification (haRPA) on a flow-based chemiluminescence microarray

Increasing numbers of legionellosis outbreaks within the last years have shown that Legionella are a growing challenge for public health. Molecular biological detection methods capable of rapidly identifying viable Legionella are important for the control of engineered water systems. The current gold standard based on culture methods takes up to 10 days to show positive results. For this reason, a flow-based chemiluminescence (CL) DNA microarray was developed that is able to quantify viable and non-viable Legionella spp. as well as Legionella pneumophila in one hour. An isothermal heterogeneous asymmetric recombinase polymerase amplification (haRPA) was carried out on flow-based CL DNA microarrays. Detection limits of 87 genomic units (GU) µL^-1 and 26GUµL^-1 for Legionella spp. and Legionella pneumophila, respectively, were achieved. In this work, it was shown for the first time that the combination of a propidium monoazide (PMA) treatment with haRPA, the so-called viability haRPA, is able to identify viable Legionella on DNA microarrays. Different proportions of viable and non-viable Legionella, shown with the example of L. pneumophila, ranging in a total concentration between 10¹ to 10⁵GUµL^-1 were analyzed on the microarray analysis platform MCR 3. Recovery values for viable Legionella spp. were found between 81% and 133%. With the combination of these two methods, there is a chance to replace culture-based methods in the future for the monitoring of engineered water systems like condensation recooling plants.