Direct healthcare costs of selected diseases primarily or partially transmitted by water

Leading Paediatric Infectious Diseases-Current Trends, Gaps, and Future Prospects in Oral Pharmacotherapeutic Interventions

Paediatric infectious diseases contribute significantly to global health challenges. Conventional therapeutic interventions are not always suitable for children, as they are regularly accompanied with long-standing disadvantages that negatively impact efficacy, thus necessitating the need for effective and child-friendly pharmacotherapeutic interventions. Recent advancements in drug delivery technologies, particularly oral formulations, have shown tremendous progress in enhancing the effectiveness of paediatric medicines. Generally, these delivery methods target, and address challenges associated with palatability, dosing accuracy, stability, bioavailability, patient compliance, and caregiver convenience, which are important factors that can influence successful treatment outcomes in children. Some of the emerging trends include moving away from creating liquid delivery systems to developing oral solid formulations, with the most explored being orodispersible tablets, multiparticulate dosage forms using film-coating technologies, and chewable drug products. Other ongoing innovations include gastro-retentive, 3D-printed, nipple-shield, milk-based, and nanoparticulate (e.g., lipid-, polymeric-based templates) drug delivery systems, possessing the potential to improve therapeutic effectiveness, age appropriateness, pharmacokinetics, and safety profiles as they relate to the paediatric population. This manuscript therefore highlights the evolving landscape of oral pharmacotherapeutic interventions for leading paediatric infectious diseases, crediting the role of innovative drug delivery technologies. By focusing on the current trends, pointing out gaps, and identifying future possibilities, this review aims to contribute towards ongoing efforts directed at improving paediatric health outcomes associated with the management of these infectious ailments through accessible and efficacious drug treatments.

Quantitative microbial risk assessment of gastrointestinal illness due to recreational exposure to E. coli and enterococci on the southern coasts of the Caspian Sea

Background

Gastrointestinal illness refers to a broad range of diseases that affect the digestive system, including infections caused by bacteria, viruses, and parasites. Quantitative Microbial Risk Assessment (QMRA) is a powerful tool used to evaluate the risks associated with microbial pathogens in various environments. The main objective of this study was to conduct a quantitative assessment of gastrointestinal illnesses that occur as a result of exposure to E. coli and enterococci during recreational activities on the southern coasts of the Caspian Sea.

Methods

Samples were collected from the recreational beaches along the border line of the Caspian Sea. The samples were analyzed for the presence and enumeration of E. coli and enterococci using the microplate method and membrane filtration techniques. Then, the annual and daily infection risks were computed using the Monte Carlo simulation approach.

Results

The results revealed that the risk of daily and annual infections on the coasts of Babolsar was higher than that on the coasts of Sari. Also, in the recreational waters of these beaches, the risk of infection by enterococci was higher than that posed by E. coli. In Babolsar, the average annual infection risk caused by E. coli and enterococci was 0.365 and 1 for children and 0.181 and 0.986 for adults. Also, in Sari, the average annual infection risk caused by E. coli and enterococci was 0.060 and 0.908 for children and 0.027 and 0.815 for adults. In addition, children were more likely than adults to become infected.

Conclusion

In light of the study's findings, due to the entry of untreated urban wastewater into the southern part of the Caspian Sea (northern Iran) and the high risk of infectious diseases for children, more control and health measures are necessary for children's swimming.

Inflammatory Patterns Associated with Legionella in HIV and Pneumonia Coinfections

Legionella infections have a propensity for occurring in HIV-infected individuals, with immunosuppressed individuals tending to present with more severe disease. However, understanding regarding the Legionella host response in immune compromised individuals is lacking. This study investigated the inflammatory profiles associated with Legionella infection in patients hospitalized with HIV and pneumonia in Medellín, Colombia from February 2007 to April 2014, and correlated these profiles with clinical outcomes. Sample aliquots from the Colombian cohort were shipped to Canada where Legionella infections and systemic cytokine profiles were determined using real-time PCR and bead-based technology, respectively. To determine the effect of Legionella coinfection on clinical outcome, a patient database was consulted, comparing laboratory results and outcomes between Legionella-positive and -negative individuals. Principal component analysis revealed higher plasma concentrations of eotaxin, IP-10 and MCP-1 (p = 0.0046) during Legionella infection. Individuals with this immune profile also had higher rates of intensive care unit admissions (adjusted relative risk 1.047 [95% confidence interval 1.027-1.066]). Results demonstrate that systemic markers of monocyte/macrophage activation and differentiation (eotaxin, MCP-1, and IP-10) are associated with Legionella infection and worse patient outcomes. Further investigations are warranted to determine how this cytokine profile may play a role in Legionella pneumonia pathogenesis or immunity.

Antigiardial and antiamebic activities of fexinidazole and its metabolites: new drug leads for giardiasis and amebiasis

The intestinal parasites Giardia lamblia and Entamoeba histolytica are major causes of morbidity and mortality associated with diarrheal diseases. Metronidazole is the most common drug used to treat giardiasis and amebiasis. Despite its efficacy, treatment failures in giardiasis occur in up to 5%-40% of cases. Potential resistance of E. histolytica to metronidazole is an increasing concern. Therefore, it is critical to search for more effective drugs to treat giardiasis and amebiasis. We identified antigiardial and antiamebic activities of the rediscovered nitroimidazole compound, fexinidazole, and its sulfone and sulfoxide metabolites. Fexinidazole is equally active against E. histolytica and G. lamblia trophozoites, and both metabolites were 3- to 18-fold more active than the parent drug. Fexinidazole and its metabolites were also active against a metronidazole-resistant strain of G. lamblia. G. lamblia and E. histolytica cell extracts exhibited decreased residual nitroreductase activity when metabolites were used as substrates, indicating nitroreductase may be central to the mechanism of action of fexinidazole. In a cell invasion model, fexinidazole and its metabolites significantly reduced the invasiveness of E. histolytica trophozoites through basement membrane matrix. A q.d. oral dose of fexinidazole and its metabolites at 10 mg/kg for 3 days reduced G. lamblia infection significantly in mice compared to control. The newly discovered antigiardial and antiamebic activities of fexinidazole, combined with its FDA-approval and inclusion in the WHO Model List of Essential Medicines for the treatment of human African trypanosomiasis, offer decreased risk and a shortened development timeline toward clinical use of fexinidazole for treatment of giardiasis or amebiasis.

Premise Plumbing Pipe Materials and In-Building Disinfectants Shape the Potential for Proliferation of Pathogens and Antibiotic Resistance Genes

In-building disinfectants are commonly applied to control the growth of pathogens in plumbing, particularly in facilities such as hospitals that house vulnerable populations. However, their application has not been well optimized, especially with respect to interactive effects with pipe materials and potential unintended effects, such as enrichment of antibiotic resistance genes (ARGs) across the microbial community. Here, we used triplicate convectively mixed pipe reactors consisting of three pipe materials (PVC, copper, and iron) for replicated simulation of the distal reaches of premise plumbing and evaluated the effects of incrementally increased doses of chlorine, chloramine, chlorine dioxide, and copper-silver disinfectants. We used shotgun metagenomic sequencing to characterize the resulting succession of the corresponding microbiomes over the course of 37 weeks. We found that both disinfectants and pipe material affected ARG and microbial community taxonomic composition both independently and interactively. Water quality and total bacterial numbers were not found to be predictive of pathogenic species markers. One result of particular concern was the tendency of disinfectants, especially monochloramine, to enrich ARGs. Metagenome assembly indicated that many ARGs were enriched specifically among the pathogenic species. Functional gene analysis was indicative of a response of the microbes to oxidative stress, which is known to co/cross-select for antibiotic resistance. These findings emphasize the need for a holistic evaluation of pathogen control strategies for plumbing.

Water, Water Everywhere, but Every Drop Unique: Challenges in the Science to Understand the Role of Contaminants of Emerging Concern in the Management of Drinking Water Supplies

The protection and management of water resources continues to be challenged by multiple and ongoing factors such as shifts in demographic, social, economic, and public health requirements. Physical limitations placed on access to potable supplies include natural and human-caused factors such as aquifer depletion, aging infrastructure, saltwater intrusion, floods, and drought. These factors, although varying in magnitude, spatial extent, and timing, can exacerbate the potential for contaminants of concern (CECs) to be present in sources of drinking water, infrastructure, premise plumbing and associated tap water. This monograph examines how current and emerging scientific efforts and technologies increase our understanding of the range of CECs and drinking water issues facing current and future populations. It is not intended to be read in one sitting, but is instead a starting point for scientists wanting to learn more about the issues surrounding CECs. This text discusses the topical evolution CECs over time (Section 1), improvements in measuring chemical and microbial CECs, through both analysis of concentration and toxicity (Section 2) and modeling CEC exposure and fate (Section 3), forms of treatment effective at removing chemical and microbial CECs (Section 4), and potential for human health impacts from exposure to CECs (Section 5). The paper concludes with how changes to water quantity, both scarcity and surpluses, could affect water quality (Section 6). Taken together, these sections document the past 25 years of CEC research and the regulatory response to these contaminants, the current work to identify and monitor CECs and mitigate exposure, and the challenges facing the future.

Impact of a quality improvement programme on the preparation and administration of medications via a nasoenteral feeding tube: 2014-2019 intervention study

AIMS

Evaluate the impact of a quality improvement programme on the reduction of feeding tube obstruction frequencies, analyse the predictive variables of this safety incident, and estimate the economic costs related to the quality improvement programme during the period from 2014 to 2019.

METHODS

Plan-Do-Study-Act cycles were performed to test the changes in drug preparation and administration processes via a nasoenteral feeding tube and to evaluate the outcome, process and balance measures. Statistical control charts were elaborated, and the bottom-up direct costing methodology was used to estimate the costs of the improvement programme. The impact of the programme on the monitoring measures was evaluated using logistic regression analysis.

INTERVENTIONS

The following changes were tested in the hospital participating in the study: acquisition of the Easy Crush equipment for tablet crushing, use of appropriate packaging to crush hard tablets, standardise procedures for scheduling administration times and/or substitution of the pharmaceutical form, educational activities for the nursing team and elaboration and availability of infographics for the nursing team, patients and/or family/caregivers.

RESULTS

There was a significant improvement in the frequency of tube obstructions, from 41.1% in 2014 to 57.9% in 2015-2017 and 9.6% in 2018-2019 (p=0.0010). After the execution of the improvement programme, it was estimated that the cost of dose preparation was reduced from R$1067.50 in 2014 to R$719.80 in 2015-2017 and R$433.10 in 2015-2019.

CONCLUSION

By re-establishing the processes of drug preparation and administration via a nasoenteral feeding tube, through the acquisition of appropriate equipment for crushing hard tablets, together with educational activities for the nursing team, we could observe a reduction in tube obstructions and the cost of processes.

(Mis)perception and Use of Unsterile Water in Home Medical Devices, PN View 360+ Survey, United States, August 20211

Tap water is not sterile, and its use in home medical devices can result in infections from waterborne pathogens. However, many participants in a recent survey in the United States said tap water could safely be used for home medical devices. These results can inform communication materials to reduce the high consequence of infections.

Slippery lubricant-infused silica nanoparticulate film processing for anti-biofouling applications

Microbial biofilm build-up in water distribution systems can pose a risk to human health and pipe material integrity. The impact is more devastating in space stations and to astronauts due to the isolation from necessary replacement parts and medical resources. As a result, there is a need for coatings to be implemented onto the inner region of the pipe to minimize the adherence and growth of biofilms. Lubricant-infused surfaces has been one such interesting material for anti-biofouling applications in which their slippery property promotes repellence to many liquids and thus prevents bacterial adherence. Textured and porous films are suitable substrate candidates to infuse and contain the lubricant. However, there is little investigation in utilizing a nanoparticulate thin film as the substrate material for lubricant infusion. A nanoparticulate film has high porosity within the structure which can promote greater lubricant infusion and retention. The implementation as a thin film structure aids to reduce material consumption and cost. In our study, we utilized a well-studied nanoporous thin film fabricated via layer-by-layer assembly of polycations and colloid silica and then calcination for greater stability. The film was further functionalized to promote fluorinated groups and improve affinity with a fluorinated lubricant. The pristine nanoporous film was characterized to determine its morphology, thickness, wettability, and porosity. The lubricant-infused film was then tested for its lubricant layer stability upon various washing conditions and its performance against bacterial biofilm adherence as a result of its slippery property. Overall, the modified silica nanoparticulate thin film demonstrated potential as a base substrate for lubricant-infused surface fabrication that repelled against ambient aqueous solvents and as an anti-biofouling coating that demonstrated low biofilm coverage and colony forming unit values. Further optimization to improve lubricant retention or incorporation of a secondary function can aid in developing better coatings for biofilm mitigation.

Direct Outpatient Health Care Costs Among Commercially Insured Persons for Common Foodborne Pathogens and Acute Gastroenteritis, 2012-2015

Foodborne illness is common in the United States with most, but not all, foodborne pathogens causing symptoms of acute gastroenteritis (AGI). Outpatient care is the most frequent type of medical care sought; however, more accurate estimates of outpatient costs are needed to inform food safety policy decision. Using the U.S. MarketScan Commercial Claims and Encounters database, we quantified the per-visit cost of outpatient visits with any AGI-related diagnosis (including pathogen-specific and nonspecific or symptom-based diagnoses) and for those with a pathogen-specific diagnosis for 1 of 29 pathogens commonly transmitted through food (including pathogens that cause AGI and some that do not). Our estimates included the per-case cost of office visits and associated laboratory tests and procedures as well as the conservative estimates of prescription cost. Most AGI outpatient visits were coded using nonspecific codes (e.g., infectious gastroenteritis), rather than pathogen-specific codes (e.g., Salmonella). From 2012 to 2015, we identified more than 3.4 million initial outpatient visits with any AGI diagnosis and 45,077 with a foodborne pathogen-specific diagnosis. As is typical of treatment cost data, severe cases of illness drove mean costs above median. The mean cost of an outpatient visit with any AGI was $696 compared with the median of $162. The mean costs of visits with pathogen-specific diagnoses ranged from $254 (median $131; interquartile range [IQR]: $98-184) for Streptococcus spp. Group A (n = 22,059) to $1761 (median $161; IQR: $104-$1101) for Clostridium perfringens (n = 30). Visits with two of the most common causes of foodborne illness, nontyphoidal Salmonella and norovirus, listed as a diagnosis, had mean costs of $841 and $509, respectively. Overall, the median per-case costs of outpatient visits increased with age, with some variation by pathogen. More empirically based estimates of outpatient costs for AGI and specific pathogens can enhance estimates of the economic cost of foodborne illness used to guide food policy and focus prevention efforts.

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.

Advances in application of ultraviolet irradiation for biofilm control in water and wastewater infrastructure

Biofilms are ubiquitous in aquatic environment. While so far, most of the ultraviolet (UV) disinfection studies focus on planktonic bacteria, and only limited attention has been given to UV irradiation on biofilms. To enrich this knowledge, the present paper reviews the up-to-date studies about applying UV to control biofilms in water and wastewater infrastructure. The development of UV light sources from the conventional mercury lamp to the light emitting diode (LED), and the resistance mechanisms of biofilms to UV are summarized, respectively. Then the feasibility to control biofilms with UV is discussed in terms of three technical routes: causing biofilm slough, inhibiting biofilm formation, and inactivating bacteria in the established biofilm. A comprehensive evaluation of the biofilm-targeted UV technologies currently used or potentially useful in water industry is provided as well, after comparative analyses on single/combined wavelengths, continuous/pulsed irradiation, and instant/chronic disinfection effects. UV LEDs are emerging as competitive light sources because of advantages such as possible selection of wavelengths, adjustable emitting mode and the designable configuration. They still, however, face challenges arising from the low wall plug efficiency and power output. At last, the implementation of the UV-based advanced oxidation processes in controlling biofilms on artificial surfaces is overviewed and their synergistic mechanisms are proposed, which further enlightens the prospective of UV in dealing with the biofilm issue in water infrastructure.

Regulatory network controls microbial biofilm development, with Candida albicans as a representative: from adhesion to dispersal

Microorganisms mainly exist in the form of biofilm in nature. Biofilm can contaminate food and drinking water system, as well as cause chronic wound infections, thereby posing a potential threat to public health safety. In the last two decades, researchers have made efforts to investigate the genetic contributors control different stages of biofilm development (adherence, initiation, maturation, and dispersal). As an opportunistic pathogen, C. albicans causes severe superficial or systemic infections with high morbidity and mortality under conditions of immune dysfunction. It has been reported that 80% of C. albicans infections are directly or indirectly associated with biofilm formation on host or abiotic surfaces including indwelling medical devices, resulting in high morbidity and mortality. Significantly, the outcome of C. albicans biofilm development includes enhanced invasion, exacerbated inflammatory responses and intrinsic resistance to antimicrobial chemotherapy. Thus, this review aimed at providing a comprehensive overview of the regulatory network controls microbial biofilm development, with C. albicans as a representative, served as reference for therapeutic targets.

A review of legionnaires' disease and public water systems - Scientific considerations, uncertainties and recommendations

Legionella is an opportunistic premise plumbing pathogen and causative agent of a severe pneumonia called Legionnaires' Disease (LD). Cases of LD have been on the rise in the U.S. and globally. Although Legionella was first identified 45 years ago, it remains an 'emerging pathogen." Legionella is part of the normal ecology of a public water system and is frequently detected in regulatory-compliant drinking water. Drinking water utilities, regulators and public health alike are increasingly required to have a productive understanding of the evolving issues and complex discussions of the contribution of the public water utility to Legionella exposure and LD risk. This review provides a brief overview of scientific considerations important for understanding this complex topic, a review of findings from investigations of public water and LD, including data gaps, and recommendations for professionals interested in investigating public water utilities. Although the current literature is inconclusive in identifying a public water utility as a sole source of an LD outbreak, the evidence is clear that minimizing growth of Legionella in public water utilities through proper maintenance and sustained disinfectant residuals, throughout all sections of the water utility, will lead to a less conducive environment for growth of the bacteria in the system and the buildings they serve.

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).

Racial Disparities in Incidence of Legionnaires' Disease and Social Determinants of Health: A Narrative Review

OBJECTIVES

Racial and socioeconomic disparities in the incidence of Legionnaires' disease have been documented for the past 2 decades; however, the social determinants of health (SDH) that contribute to these disparities are not well studied. The objective of this narrative review was to characterize SDH to inform efforts to reduce disparities in the incidence of Legionnaires' disease.

METHODS

We conducted a narrative review of articles published from January 1979 through October 2019 that focused on disparities in the incidence of Legionnaires' disease and pneumonia (inclusive of bacterial pneumonia and/or community-acquired pneumonia) among adults and children (excluding articles that were limited to people aged <18 years). We identified 220 articles, of which 19 met our criteria: original research, published in English, and examined Legionnaires' disease or pneumonia, health disparities, and SDH. We organized findings using the Healthy People 2030 SDH domains: economic stability, education access and quality, social and community context, health care access and quality, and neighborhood and built environment.

RESULTS

Of the 19 articles reviewed, multiple articles examined disparities in incidence of Legionnaires' disease and pneumonia related to economic stability/income (n = 13) and comorbidities (n = 10), and fewer articles incorporated SDH variables related to education (n = 3), social support (none), health care access (n = 1), and neighborhood and built environment (n = 6) in their analyses.

CONCLUSIONS

Neighborhood and built-environment factors such as housing, drinking water infrastructure, and pollutant exposures represent critical partnership and research opportunities. More research that incorporates SDH and multilevel, cross-sector interventions is needed to address disparities in Legionnaires' disease incidence.

Quantification of Legionella pneumophila by qPCR and culture in tap water with different concentrations of residual disinfectants and heterotrophic bacteria

Legionellosis prevalence is increasing in the United States. This disease is caused primarily by the bacterium Legionella pneumophila found in water and transmitted by aerosol inhalation. This pathogen has a slow growth rate and can "hide" in amoeba, making it difficult to monitor by the traditional culture method on selective media. Tap water samples (n = 358) collected across the United States were tested for L. pneumophila by both culture and quantitative Polymerase Chain Reaction (qPCR). The presence of other bacteria was quantified by heterotrophic plate counts (HPC). Residual disinfectant concentrations (free chlorine or monochloramine) were measured in all samples. Legionella pneumophila had the highest prevalence and concentration in the chlorinated water samples that had a free‑chlorine value of less than 0.2 mg Cl₂/L. In total, 24% (87/358) of the samples were positive for L. pneumophila either by qPCR or 3% (11/358) were positive by culture. In chloramine-treated samples, L. pneumophila was detected by qPCR in 21% (31/148) and 1% (2/148) by culture, despite a high monochloramine residual >1 mg Cl₂/L. Despite the presence of a high disinfectant residual (>1 mg Cl₂/L), HPC counts were substantial. This study indicates that both culture and qPCR methods have limitations when predicting a potential risk for disease associated with L. pneumophila in tap water. Measuring disinfectant residuals and quantifying HPC in water samples may be useful adjunct parameters for reducing Legionellosis' risk from public water supplies at high-risk locations.

Estimate of Burden and Direct Healthcare Cost of Infectious Waterborne Disease in the United States

Provision of safe drinking water in the United States is a great public health achievement. However, new waterborne disease challenges have emerged (e.g., aging infrastructure, chlorine-tolerant and biofilm-related pathogens, increased recreational water use). Comprehensive estimates of the health burden for all water exposure routes (ingestion, contact, inhalation) and sources (drinking, recreational, environmental) are needed. We estimated total illnesses, emergency department (ED) visits, hospitalizations, deaths, and direct healthcare costs for 17 waterborne infectious diseases. About 7.15 million waterborne illnesses occur annually (95% credible interval [CrI] 3.88 million–12.0 million), results in 601,000 ED visits (95% CrI 364,000–866,000), 118,000 hospitalizations (95% CrI 86,800–150,000), and 6,630 deaths (95% CrI 4,520–8,870) and incurring US $3.33 billion (95% CrI 1.37 billion–8.77 billion) in direct healthcare costs. Otitis externa and norovirus infection were the most common illnesses. Most hospitalizations and deaths were caused by biofilm-associated pathogens (nontuberculous mycobacteria, Pseudomonas, Legionella), costing US $2.39 billion annually.

Are Fluoroquinolones or Macrolides Better for Treating Legionella Pneumonia? A Systematic Review and Meta-analysis

BACKGROUND

The Infectious Diseases Society of America recommends either a fluoroquinolone or a macrolide as a first-line antibiotic treatment for Legionella pneumonia, but it is unclear which antibiotic leads to optimal clinical outcomes. We compared the effectiveness of fluoroquinolone versus macrolide monotherapy in Legionella pneumonia using a systematic review and meta-analysis.

METHODS

We conducted a systematic search of literature in PubMed, Cochrane, Scopus, and Web of Science from inception to 1 June 2019. Randomized controlled trials and observational studies comparing macrolide with fluoroquinolone monotherapy using clinical outcomes in patients with Legionella pneumonia were included. Twenty-one publications out of an initial 2073 unique records met the selection criteria. Following PRISMA guidelines, 2 reviewers participated in data extraction. The primary outcome was mortality. Secondary outcomes included clinical cure, time to apyrexia, length of hospital stay (LOS), and the occurrence of complications. The review and meta-analysis was registered with PROSPERO (CRD42019132901).

RESULTS

Twenty-one publications with 3525 patients met inclusion criteria. The mean age of the population was 60.9 years and 67.2% were men. The mortality rate for patients treated with fluoroquinolones was 6.9% (104/1512) compared with 7.4% (133/1790) among those treated with macrolides. The pooled odds ratio assessing risk of mortality for patients treated with fluoroquinolones versus macrolides was 0.94 (95% confidence interval, .71-1.25, I2 = 0%, P = .661). Clinical cure, time to apyrexia, LOS, and the occurrence of complications did not differ for patients treated with fluoroquinolones versus macrolides.

CONCLUSIONS

We found no difference in the effectiveness of fluoroquinolones versus macrolides in reducing mortality among patients with Legionella pneumonia.

Appearance of mcr-9, blaKPC, cfr and other clinically relevant antimicrobial resistance genes in recreation waters and sands from urban beaches, Brazil

The co-occurrence of mcr-like and carbapenemase-encoding genes have been reported mainly in humans and animals, whereas, in the environment, studies are gradually increasing due to the One Health approach. In this study, we investigated antimicrobial resistance genes (ARGs) in water and sand samples from marine environments in Brazil. Total DNA from 56 samples (33 sands and 23 waters) was obtained and 27 different ARGs were detected, highlighting the presence of mcr-9, bla_KPC and cfr genes. Additionally, the microbiological analysis revealed that sand samples of all analyzed beaches were not recommended for primary use, whereas water samples from most beaches were classified as unsuitable for bathing. The presence of clinically relevant ARGs in urban beaches suggests the presence of antimicrobial-resistant bacteria. Furthermore, to the best of our knowledge, this is the first report of mcr-9 and cfr genes in the environment from Brazil and recreational areas worldwide.

Optimizing disinfectant residual dosage in engineered water systems to minimize the overall health risks of opportunistic pathogens and disinfection by-products

This Discussion argues that municipal water utilities may need to consider the health risks of both opportunistic pathogens (OPs) and disinfection by-products (DBPs) while selecting disinfectant residual dosages or levels in engineered water systems. OPs are natural inhabitants in municipal water systems and the leading cause of drinking-water-related disease outbreaks threatening public health. DBPs in water systems are genotoxic/carcinogenic and also significantly affect public health. Disinfectant residuals (such as free chlorine and chloramine residuals) dictate OP (re)growth and DBP formation in engineered water systems. Therefore, regulating the dosages or levels of disinfectant residuals is effective in controlling OP (re)growth and DBP formation. Existing effects assessing optimal disinfectant residual dosages focus solely on minimizing OP (re)growth or solely on DBP formation. However, selecting disinfectant residual dosages aiming to solely limit the formation of DBPs might compromise OP (re)growth control, and vice versa. An optimal disinfectant residual level for DBP formation control or OP (re)growth control might not be optimal for minimizing the overall or combined health effects of OPs and DBPs in drinking water. To better protect public health, water authorities may need to update the current residual disinfection practice and maintain disinfectant residuals in engineered water systems at an optimal level to minimize the overall health risks of OPs and DBPs.

Evaluation of a new culture medium for isolation of nontuberculous mycobacteria from environmental water samples

Nontuberculous mycobacteria (NTM) are waterborne pathogens commonly found in building water systems where they are a primary concern to vulnerable patient populations and can cause severe disease. The recovery of NTM from environmental samples can be a laborious undertaking and current pre-treatment methods and selective media lack sensitivity. We explored the use of the highly selective Rapidly Growing Mycobacteria (RGM) medium for culturing NTM from environmental water samples compared to existing methods. In total, 223 environmental water samples, including potable and non-potable water, were cultured for NTM using three culture media. In addition to direct culture on RGM medium, each sample was cultured on Middlebrook 7H10 medium and Mitchison 7H11 medium after pre-treatment with 0.2M KCl-HCl. Additionally, 33 distinct species of NTM were inoculated onto RGM medium and 7H10 medium in parallel to directly compare their growth. The use of RGM medium alone without pre-treatment provided a sensitivity (91%) comparable to that offered by culture on both 7H10 and 7H11 with acid pretreatment (combined sensitivity; 86%) with significantly less overgrowth and interference from other organisms on RGM medium. The average concentration of NTM observed on RGM medium alone was comparable to or greater than the NTM concentration on either medium alone or combined. Thirty-three species were examined in parallel and all tested strains of 27 of these species successfully grew on RGM medium, including 19 of 21 from the CDC’s healthcare-associated infections species list. RGM medium was successful at recovering environmental NTM without a pre-treatment, greatly reducing labor and materials required to process samples. Simplification of culture processing for environmental NTM will allow for a better assessment of their presence in building water systems and the potential for reduced exposure of susceptible populations.

Attribution of Illnesses Transmitted by Food and Water to Comprehensive Transmission Pathways Using Structured Expert Judgment, United States

Illnesses transmitted by food and water cause a major disease burden in the United States despite advancements in food safety, water treatment, and sanitation. We report estimates from a structured expert judgment study using 48 experts who applied Cooke's classical model of the proportion of disease attributable to 5 major transmission pathways (foodborne, waterborne, person-to-person, animal contact, and environmental) and 6 subpathways (food handler-related, under foodborne; recreational, drinking, and nonrecreational/nondrinking, under waterborne; and presumed person-to-person-associated and presumed animal contact-associated, under environmental). Estimates for 33 pathogens were elicited, including bacteria such as Salmonella enterica, Campylobacter spp., Legionella spp., and Pseudomonas spp.; protozoa such as Acanthamoeba spp., Cyclospora cayetanensis, and Naegleria fowleri; and viruses such as norovirus, rotavirus, and hepatitis A virus. The results highlight the importance of multiple pathways in the transmission of the included pathogens and can be used to guide prioritization of public health interventions.

Living with Legionella and Other Waterborne Pathogens

Legionella spp. and other opportunistic premise plumbing pathogens (OPPPs), including Pseudomonas aeruginosa, Mycobacterium avium, Stenotrophomonas maltophilia, and Acinetobacter baumannii, are normal inhabitants of natural waters, drinking water distribution systems and premise plumbing. Thus, humans are regularly exposed to these pathogens. Unfortunately, Legionella spp. and the other OPPPs share a number of features that allow them to grow and persist in premise plumbing. They form biofilms and are also relatively disinfectant-resistant, able to grow at low organic matter concentrations, and able to grow under stagnant conditions. Infections have been traced to exposure to premise plumbing or aerosols generated in showers. A number of measures can lead to reduction in OPPP numbers in premise plumbing, including elevation of water heater temperatures.

Travel-associated cases of Legionnaires' disease in the United States, 2015-2016

BACKGROUND

Recent travel is associated with ~20% of reported Legionnaires' disease (LD) cases worldwide.

METHODS

We analyzed LD cases reported to the Centers for Disease Control and Prevention (CDC) during 2015-2016. Travel-associated cases met case criteria for confirmed LD in someone who spent ≥1 night away from home during the 10 days before symptom onset. Most analyses were limited to travel-associated, public accommodation stay (TAPAS) cases. We used reported travel dates to estimate the number of TAPAS cases acquired during travel.

RESULTS

Of 12,200 LD cases reported among U.S. residents, 12.3% were travel-associated; 8.7% were TAPAS. Median patient age for TAPAS cases was 61 years; 64.4% were male; 67.3% were white; 77.9% were non-Hispanic; 96.1% were hospitalized; 4.5% died. Among 887 TAPAS cases involving U.S. destinations, an estimated 29.8% were acquired during travel; 4.28 TAPAS cases were reported, and an estimated 1.10 TAPAS cases were acquired during travel, per 10,000,000 hotel room nights booked. Sixty-eight U.S. TAPAS clusters were detected.

CONCLUSIONS

While acquisition during travel accounted for a relatively small proportion of all LD cases, clusters of TAPAS cases were frequently detected. Prompt notification of these cases to CDC facilitates cluster detection and expedites intervention.

Cost-benefit analysis of point-of-use devices for health risks reduction from pathogens in drinking water

Microbial contamination of drinking water post-municipal treatment is difficult to predict as a risk factor for human health. One method to reduce morbidity or mortality from unpredictable exposures is through point-of-use (POU) treatment devices. The goal of this project was to assess the cost-benefit of POU water treatment at the tap in terms of protection from microbes in drinking water. This project estimated: (1) incidence of acute illness (AI), sequela, and mortality associated with waterborne pathogens; (2) illness reduction rates from using POU devices; and (3) healthcare cost reductions associated with POU devices. Infection rates and costs associated with 10 of the most common waterborne pathogens were identified and used to calculate national annual costs. We estimated 9M AI, 0.6M sequela, and 1,400 mortality cases that occur annually in the USA from these pathogens. The greatest cost-benefit was seen when considering the totality of disease burden reduction (AI, sequela, and mortality) including all pathogens at a national level and applying a 35% infection reduction, resulting in a total cost per averted disease case of $1,815. This study suggests that it is cost-beneficial to prevent water-related illness using POU devices.

Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) in drinking water fountains in urban parks

The presence of Staphylococcus aureus in drinking water is a concern because of its potential to cause human infection and also because of its multiple antimicrobial resistance. This study evaluated the water quality of drinking water fountains and mist makers in four municipal parks of São Paulo for 13 months. Although all samples met bacteriological water quality criteria according to Brazilian regulations, the absence of residual chlorine (<0.1 mg/L) was observed. These data were significantly correlated with the frequency of S. aureus that was found in 25.2% of the samples. The mecA gene was detected in 36.7% of the isolates demonstrating its potential for resistance to several antimicrobials. Furthermore, 27.3% isolates carrying the mecA gene had methicillin-resistant Staphylococcus aureus (MRSA) phenotypic potential. The presence of S. aureus with characteristics of microbial resistance in water for human consumption is an unprecedented finding. Hence, conducting surveillance for opportunistic bacteria, such as staphylococci in drinking water, is reasonable to take control measures and to protect human health, especially in public places with high attendance.

Chlorine Disinfection of Legionella spp., L. pneumophila, and Acanthamoeba under Warm Water Premise Plumbing Conditions

Premise plumbing conditions can contribute to low chlorine or chloramine disinfectant residuals and reactions that encourage opportunistic pathogen growth and create risk of Legionnaires' Disease outbreaks. This bench-scale study investigated the growth of Legionella spp. and Acanthamoeba in direct contact with premise plumbing materials-glass-only control, cross-linked polyethylene (PEX) pipe, magnesium anode rods, iron pipe, iron oxide, pH 10, or a combination of factors. Simulated glass water heaters (SGWHs) were colonized by Legionella pneumophila and exposed to a sequence of 0, 0.1, 0.25, and 0.5 mg/L chlorine or chloramine, at two levels of total organic carbon (TOC), over 8 weeks. Legionella pneumophila thrived in the presence of the magnesium anode by itself and or combination with other factors. In most cases, 0.5 mg/L Cl2 caused a significant rapid reduction of L. pneumophila, Legionella spp., or total bacteria (16S rRNA) gene copy numbers, but at higher TOC (>1.0 mg C/L), a chlorine residual of 0.5 mg/L Cl2 was not effective. Notably, Acanthamoeba was not significantly reduced by the 0.5 mg/L chlorine dose.

Replicable simulation of distal hot water premise plumbing using convectively-mixed pipe reactors

A lack of replicable test systems that realistically simulate hot water premise plumbing conditions at the laboratory-scale is an obstacle to identifying key factors that support growth of opportunistic pathogens (OPs) and opportunities to stem disease transmission. Here we developed the convectively-mixed pipe reactor (CMPR) as a simple reproducible system, consisting of off-the-shelf plumbing materials, that self-mixes through natural convective currents and enables testing of multiple, replicated, and realistic premise plumbing conditions in parallel. A 10-week validation study was conducted, comparing three pipe materials (PVC, PVC-copper, and PVC-iron; n = 18 each) to stagnant control pipes without convective mixing (n = 3 each). Replicate CMPRs were found to yield consistent water chemistry as a function of pipe material, with differences becoming less discernable by week 9. Temperature, an overarching factor known to control OP growth, was consistently maintained across all 54 CMPRs, with a coefficient of variation <2%. Dissolved oxygen (DO) remained lower in PVC-iron (1.96 ± 0.29 mg/L) than in PVC (5.71 ± 0.22 mg/L) or PVC-copper (5.90 ± 0.38 mg/L) CMPRs as expected due to corrosion. Further, DO in PVC-iron CMPRs was 33% of that observed in corresponding stagnant pipes (6.03 ± 0.33 mg/L), demonstrating the important role of internal convective mixing in stimulating corrosion and microbiological respiration. 16S rRNA gene amplicon sequencing indicated that both bulk water (P_adonis = 0.001, R² = 0.222, P_betadis = 0.785) and biofilm (P_adonis = 0.001, R² = 0.119, P_betadis = 0.827) microbial communities differed between CMPR versus stagnant pipes, consistent with creation of a distinct ecological niche. Overall, CMPRs can provide a more realistic simulation of certain aspects of premise plumbing than reactors commonly applied in prior research, at a fraction of the cost, space, and water demand of large pilot-scale rigs.

Bacterial viability and diversity in a landscape lake replenished with reclaimed water: a case study in Xi'an, China

To understand the characteristics of bacterial viability and diversity in landscape waters replenished with reclaimed water, the typical landscape lake using reclaimed water was investigated in this study. Samples were collected from a reclaimed water inlet (P1), a reclaimed water distribution outlet (P2), and a landscape lake replenished by reclaimed water (P3). By means of measuring adenosine triphosphate (ATP), flow cytometry (FCM), and 16S rRNA gene high-throughput sequencing, the bacterial viability and diversity in reclaimed water distribution system and landscape lake were illustrated. The bacterial ATP contents at P1, P2, and P3 were 3.55 ± 1.79 ng/L, 3.31 ± 1.43 ng/L, and 18.97 ± 6.39 μg/L, and the intact bacterial cell concentrations were 5.91 ± 0.52 × 10⁴ cells/mL, 7.95 ± 2.58 × 10⁴ cells/mL, and 5.65 ± 2.10 × 10⁶ cells/mL, respectively. These results indicated a significant increase of bacterial viability in the landscape lake. The Shannon diversity index of 6.535, 7.05, and 6.886 at P1, P2, and P3, respectively, demonstrated no notable change of bacterial diversity from reclaimed water distribution system to landscape lake. However, the relative abundance of Pseudomonas sp. at P3 was significantly higher than that at P1. These findings indicated that viable but non-culturable (VBNC) bacteria could be revived in the landscape lake. The bacterial viability during reclaimed water reuse should deserve special attention.

Epidemiologic Survey of Legionella Urine Antigen Testing Within a Large Wisconsin-Based Health Care System

Purpose

Legionella pneumophila pneumonia is a life-threatening, environmentally acquired infection identifiable via Legionella urine antigen tests (LUAT). We aimed to identify cumulative incidence, demographic distribution, and undetected disease outbreaks of Legionella pneumonia via positive LUAT in a single eastern Wisconsin health system, with a focus on urban Milwaukee County.

Methods

A multilevel descriptive ecologic study was conducted utilizing electronic medical record data from a large integrated health care system of patients who underwent LUAT from 2013 to 2017. A random sample inclusive of all positive tests was reviewed to investigate geodemographic differences among patients testing positive versus negative. Statistical comparisons used chi-squared or 2-sample t-tests; stepwise regression followed by binary logistic regression was used for multivariable analysis. Positive cases identified by LUAT were mapped to locate hotspots; positive cases versus total tests performed also were mapped by zip code.

Results

Of all LUAT performed (n=21,599), 0.68% were positive. Among those in the random sample (n=11,652), positive cases by LUAT were more prevalent in the June-November time period (86.2%) and younger patients (59.4 vs 67.7 years) and were disproportionately male (70.3% vs 29.7%) (P<0.0001 for each). Cumulative incidence was higher among nonwhite race/ethnicity (1.91% vs 1.01%, P<0.0001) but did not remain significant on multivariable analysis. Overall, 5507 tests were performed in Milwaukee County zip codes, yielding 82 positive cases by LUAT (60.7% of all positive cases in the random sample). A potential small 2016 outbreak was identified.

Conclusions

Cumulative incidence of a positive LUAT was less than 1%. LUAT testing, if done in real time by cooperative health systems, may complement public health detection of Legionella pneumonia outbreaks.

Highly heterogeneous temporal dynamics in the abundance and diversity of the emerging pathogens Arcobacter at an urban beach

While the significance of Arcobacter in clinical settings grows, the ecological dynamics of potentially pathogenic Arcobacter in coastal marine environments remains unclear. In this study, we monitored the temporal dynamics of Arcobacter at an urban beach subject to significant stormwater input and wet weather sewer overflows (WWSO). Weekly monitoring of bacterial communities over 24 months using 16S rRNA amplicon sequencing revealed large, intermittent peaks in the relative abundance of Arcobacter. Quantitative PCR was subsequently employed to track absolute abundance of Arcobacter 23S rRNA gene copies, revealing peaks in abundance reaching up to 10⁸ gene copies L^-1, with these increases statistically correlated with stormwater and WWSO intrusion. Notably, peaks in Arcobacter abundance were poorly correlated with enterococci plate counts, and remained elevated for one week following heavy rainfall. Using oligotyping we discriminated single nucleotide variants (SNVs) within the Arcobacter population, revealing 10 distinct clusters of SNVs that we defined as Arcobacter "ecotypes", with each displaying distinct temporal dynamics. The most abundant ecotype during stormwater and modelled WWSO events displayed 16S rRNA sequence similarity to A. cryaerophilius, a species previously implicated in human illness. Our findings highlight the diverse environmental drivers of Arcobacter abundance within coastal settings and point to a potentially important, yet overlooked exposure risk of these potential pathogens to humans.

Estimates of healthcare utilisation and deaths from waterborne pathogen exposure in Ontario, Canada

Burden of disease analyses can quantify the relative impact of different exposures on population health outcomes. Gastroenteritis where the causative pathogen was not determined and respiratory illness resulting from exposure to opportunistic pathogens transmitted by water aerosols have not always been considered in waterborne burden of disease estimates. We estimated the disease burden attributable to nine enteric pathogens, unspecified pathogens leading to gastroenteritis, and three opportunistic pathogens leading primarily to respiratory illness, in Ontario, Canada (population ~14 million). Employing a burden of disease framework, we attributed a fraction of annual (year 2016) emergency department (ED) visits, hospitalisations and deaths to waterborne transmission. Attributable fractions were developed from the literature and clinical input, and unattributed disease counts were obtained using administrative data. Our Monte Carlo simulation reflected uncertainty in the inputs. The estimated mean annual attributable rates for waterborne diseases were (per 100 000 population): 69 ED visits, 12 hospitalisations and 0.52 deaths. The corresponding 5th–95th percentile estimates were (per 100 000 population): 13–158 ED visits, 5–22 hospitalisations and 0.29–0.83 deaths. The burden of disease due to unspecified pathogens dominated these rates: 99% for ED visits, 63% for hospitalisations and 40% for deaths. However, when a causative pathogen was specified, the majority of hospitalisations (83%) and deaths (97%) resulted from exposure to the opportunistic pathogens Legionella spp., non-tuberculous mycobacteria and Pseudomonas spp. The waterborne disease burden in Ontario indicates the importance of gastroenteritis not traced back to a particular pathogen and of opportunistic pathogens transmitted primarily through contact with water aerosols.

Legionellosis and Recent Advances in Technologies for Legionella Control in Premise Plumbing Systems: A Review

This review discusses Legionella, among the most prolific and publicly well-known waterborne pathogens, and advances in potential treatment technologies. The number of cases associated with Legionella continues to rise, as does its public awareness. Currently, cases associated with premise plumbing account for the largest number of legionellosis cases in the United States. So, while it is important to understand Legionella as such, it is also important to investigate how to treat drinking water in premise plumbing for Legionella and other waterborne pathogens. While there are currently several methods recognized as potential means of inactivating waterborne pathogens, several shortcomings continue to plague its implementation. These methods are generally of two types. Firstly, there are chemical treatments such as chlorine, chlorine dioxide, monochloramine, ozone, and copper-silver ionization. Secondly, there are physical treatments such as thermal inactivation and media filtration. Their shortcomings range from being labor-intensive and costly to having negative health effects if not properly operated. Recently developed technologies including ultraviolet (UV) irradiation using light emitting diodes (LEDs) and innovative carbon nanotube (CNT) filters can better control waterborne pathogens by allowing for the simultaneous use of different treatment measures in plumbing systems.

Methylobacterium spp. as Emerging Opportunistic Premise Plumbing Pathogens

Methylobacterium spp. are emerging opportunistic premise plumbing pathogens. Human infections linked to premise plumbing provide evidence of their routes of infection. Cells of a collection of representative strains of different Methylobacterium species were tested for hydrophobicity by contact angle, adherence and biofilm formation on different plumbing materials, and temperature tolerance (50–60 °C); characteristics shared by OPPPs. Methylobacterium spp. strains were shown to grow in drinking water, have high cell-surface hydrophobicity, adhere to pipe surface materials, form biofilms, and survive exposure to high (60° C) temperatures. It can be concluded that Methylobacterium spp. strains share traits in common with other opportunistic premise plumbing pathogens (OPPPs).

Molecular detection of opportunistic premise plumbing pathogens in rural Louisiana's drinking water distribution system

Opportunistic premise plumbing pathogens (OPPPs) in drinking water distribution systems are responsible for causing numerous infections such as Legionnaires' disease and pneumonia through the consumption of contaminated drinking water. The incidence of opportunistic pathogens and the number of individuals at risk of contracting infections caused by these OPPPs in drinking water has risen drastically in the past decade. Preflush and postflush water samples were collected from 64 houses in a rural town in northeast Louisiana to determine drinking water quality in terms of understanding abiotic and biotic factors on potential proliferation of OPPPs. Physical and chemical water quality parameters, such as pH, temperature, dissolved oxygen, salinity, and specific conductance were also measured. The quantitative polymerase chain reaction (qPCR) results indicated that Legionella spp. had the highest prevalence and was found in 46/64 samples (72%), followed by Mycobacterium spp. which was found in 43/64 samples (67%), E. coli in 31/64 samples (48%) and, Naegleria fowleri in 4/64 samples (6%) respectively. The results indicate the persistence of Legionella spp. DNA marker in these water samples.

Quantification of bacteria in water using PLS analysis of emission spectra of fluorescence and excitation-emission matrices

Bacterial contamination of drinking water is a considerable concern for public health. Tryptophan-like fluorescence (TLF) has been widely suggested to enable fast and inexpensive monitoring and quantification of bacterial contamination of water. Typically, TLF is determined at a certain excitation (ex)/emission (em) wavelengths pair. The aim of this study was to assess fluorescence spectroscopy supported with partial least squares (PLS) algorithms as a tool for a rapid evaluation of the microbial quality of water, by comparing the use of a single ex/em wavelengths pair, of the spectrum of emission obtained at a single excitation wavelength to that of whole excitation-emission matrices (EEMs). For that, laboratory-grown Escherichia coli, Bacillus subtilis and Pseudomonas aeruginosa were studied as the model systems, as well as 90 groundwater samples from 6 different wells in Israel. The groundwater samples were characterized for fluorescence emission, coliforms, fecal coliforms, fecal streptococci and heterotrophic plate counts. The PLS analysis of emission spectra and, especially, of EEMs was capable of meaningfully reducing the detection limit of microorganisms in model systems, as compared with the single ex/em wavelengths pair-based determination commonly used, reaching a detection threshold as low as 10 CFU/ml. Use of PLS-analyzed EEMs becomes beneficial also in terms of correlation and similarity between the actual and predicted bacterial concentrations. Similarly, improved detection of bacteria was also achieved in groundwater samples. Furthermore, at a level of >10⁴ CFU/ml, use of EEMs coupled with PLS enabled discrimination between E. coli, B. subtilis and P. aeruginosa.

Managing Water Quality in Premise Plumbing: Subject Matter Experts’ Perspectives and a Systematic Review of Guidance Documents

Although many guidance documents have been developed to inform the design and operation of building water systems to ensure safe water quality, there is a lack of consensus on some topics. This study interviewed 22 subject matter experts (SMEs) to identify topics of concern for managing water quality in buildings and compared SME views with information available on these topics in 15 systematically screened important guidance documents. The study found 18 design and 11 operational topics as critical for managing water quality in buildings. No one guidance document addressed all these topics, suggesting that a compendium of available guidance is needed. SMEs most frequently recommended temperature and residual disinfectant measurements as good parameters for monitoring overall building water quality. Both SME and guidance document recommendations for temperature for controlling opportunistic pathogen growth were reasonably consistent with water heater setpoint >60 °C. However, hot water temperature recommendations varied between 50 and 55 °C for other locations (i.e., the water temperature at the tap or end of the return loop). On the contrary, recommendations for disinfectant residual levels (0.2–2.0 mg/L), flushing frequency (1–14 days), and allowable time for hot water to reach the tap (10–60 s) were not consistent. While this study was able to reconcile diverging views on some of the water quality topics, such as identifying common guidance for water heater set point to at least 60 °C, it also highlights lack of definitive guidance on other critical topics, such as residual level, flushing frequency, hot water time to tap, and the use of thermostatic mixing valves, indicating that these are significant knowledge gaps that need further investigation. The study concludes that there is a need for developing evidence-based guidance, particularly on the topics where expert opinions diverged.

Urban beaches are environmental hotspots for antibiotic resistance following rainfall

To reveal the occurrence and mechanisms for dispersal of antibiotic resistance (AbR) among the microbial assemblages inhabiting impacted coastal environments, we performed a weekly, two-year duration time-series study at two urban beaches between 2014 and 2016. We combined quantitative PCR and multiplex PCR/reverse line blot techniques to track patterns in the occurrence of 31 AbR genes, including genes that confer resistance to antibiotics that are critically important antimicrobials for human medicine. Patterns in the abundance of these genes were linked to specific microbial groups and environmental parameters by coupling qPCR and 16S rRNA amplicon sequencing data with network analysis. Up to 100-fold increases in the abundance of several AbR genes, including genes conferring resistance to quinolones, trimethoprim, sulfonamides, tetracycline, vancomycin and carbapenems, occurred following storm-water and modelled wet-weather sewer overflow events. The abundance of AbR genes strongly and significantly correlated with several potentially pathogenic bacterial OTUs regularly associated with wastewater infrastructure, such as Arcobacter, Acinetobacter, Aeromonas and Cloacibacterium. These high-resolution observations provide clear links between storm-water discharge and sewer overflow events and the occurrence of AbR in the coastal microbial assemblages inhabiting urban beaches, highlighting a direct mechanism for potentially significant AbR exposure risks to humans.

A novel screening tool for the health risk in recreational waters near estuary: The Carrying Capacity indicator

The present study aims to provide a conceptual framework to help practitioners to improve the quality of recreational waters near estuary, which may be affected by untreated wastewater from Combined Sewer Overflows (CSOs). When CSOs are activated, the concentration of bacteria (e.g., Enterococci and E. coli) in estuary increases, thereby resulting in a potential health threat to swimmers. Here, the bacterial exposure is evaluated using physically-based stochastic model for contaminant transport, while human health risk is determined by Quantitative Microbial Risk Assessment (QMRA). Based on human health risk framework, we quantify the Carrying Capacity (CC) of the recreational water body. Such an indicator is defined as the number of swimming individuals that can be sustained in a beach resort with an acceptable risk threshold. The CC increases by dilution processes and by reduction of the source concentration, which in turn depends on the improvements in the sewage system. The presented approach can be a useful screening tool for policy-makers and other stakeholders, thereby providing a potential solution to the trade-off between economic development and the sustainable ecosystem in coastal areas.

Public Health Risks Associated with Heavy Metal and Microbial Contamination of Drinking Water in Australia

Recently in Australia concerns have been raised regarding the contamination of municipal drinking water supplies with lead. This is of particular concern to children due to the impact of lead exposure on cognitive development and as such these findings have received much media attention. The response from legislators has been swift, and The Victorian School Building Authority has announced that all new schools and school upgrade works will only use lead-free tapware and piping systems. However, while the immediate replacement of lead-containing brass fittings may seem a logical and obvious response, it does not consider the potential implications on microbial contamination. This is particularly concerning given the increasing public health threat posed by opportunistic premise plumbing pathogens (OPPPs). This commentary explores this public health risk of lead exposure from plumbing materials compared to the potential public health risks from OPPPs. Non-tuberculous mycobacterium was chosen as the example OPPP, and the influence on plumbing material and its public health burden in Australia is explored. This commentary highlights the need for future research into the influence of plumbing material on OPPPs prior to any changes in legislation regarding plumbing material.

Estimated burden of disease from arsenic in drinking water supplied by domestic wells in the United States

Well water around the world can be contaminated with arsenic, a naturally occurring geological element that has been associated with myriad adverse health effects. Persons obtaining their drinking water from private wells are often responsible for well testing and water treatment. High levels of arsenic have been reported in well water-supplied areas of the United States. We quantified - in cases and dollars - the potential burden of disease associated with the ingestion of arsenic through private well drinking water supplies in the United States. To estimate cancer and cardiovascular disease burden, we developed a Monte Carlo model integrating three input streams: (1) regional concentrations of arsenic in drinking water wells across the United States; (2) dose-response relationships in the form of cancer slope factors and hazard ratios; and (3) economic cost estimates developed for morbidity endpoints using 'cost-of-illness' methods and for mortality using 'value per statistical life' estimates. Exposure to arsenic in drinking water from U.S. domestic wells is modeled to contribute 500 annual premature deaths from ischemic heart disease and 1,000 annual cancer cases (half of them fatal), monetized at $10.9 billion (2017 USD) annually. These considerable public health burden estimates can be compared with the burdens of other priority public health issues to assist in decision-making.

Predictors of Failure from Primary Therapy for Giardiasis in San Diego: A Single Institution Retrospective Review

This study aimed to determine the presence of giardiasis among HIV patients in San Diego, the rate of failure of metronidazole treatment, and factors associated with treatment failure. We used a 7 year retrospective single-center case series of HIV-infected individuals with giardiasis at University of California San Diego Medical Center. Data were analyzed for the changes in the hematological, biochemical, and immunologic results at pre- and at-diagnosis levels. We also compared the changes at the diagnosis level among patients who were treated successfully and those who experienced treatment failure as defined by retreatment with a second course of antibiotics. In 29 Giardia lamblia-infected HIV patients, following diagnosis of G. lamblia, there was a non-significant decrement in cluster of differentiation 4 (CD4), but a statistically significant increase in the number of white blood cell (WBC). Other indices did not differ between pre- and at-diagnosis levels. Twenty patients (69%) were treated with a single course of metronidazole or tinidazole and seven patients (24.1%) were treated with more than one course of metronidazole. These seven patients had statistically significant higher hemoglobin at the time of diagnosis, but further studies are required to confirm if this is a consistent finding and if this can predict failure from primary therapy.

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.

Inhaled Antibiotics for Mycobacterial Lung Disease

Mycobacterial lung diseases are an increasing global health concern. Tuberculosis and nontuberculous mycobacteria differ in disease severity, epidemiology, and treatment strategies, but there are also a number of similarities. Pathophysiology and disease progression appear to be relatively similar between these two clinical diagnoses, and as a result these difficult to treat pulmonary infections often require similarly extensive treatment durations of multiple systemic drugs. In an effort to improve treatment outcomes for all mycobacterial lung diseases, a significant body of research has investigated the use of inhaled antibiotics. This review discusses previous research into inhaled development programs, as well as ongoing research of inhaled therapies for both nontuberculous mycobacterial lung disease, and tuberculosis. Due to the similarities between the causative agents, this review will also discuss the potential cross-fertilization of development programs between these similar-yet-different diseases. Finally, we will discuss some of the perceived difficulties in developing a clinically utilized inhaled antibiotic for mycobacterial diseases, and potential arguments in favor of the approach.

Retrospective Analysis of Nontuberculous Mycobacterial Infection and Monochloramine Disinfection of Municipal Drinking Water in Michigan

Infections by nontuberculous mycobacteria (NTM) result in significant morbidity, mortality, and health care costs. NTM are primarily acquired from environmental sources, including exposure to municipally treated drinking water. Higher levels of NTM have been reported in drinking water disinfected with monochloramine than in drinking water disinfected with chlorine. Our results suggest that municipal drinking water disinfection with monochloramine compared to chlorine is not associated with higher risk of NTM infection. This is important given that regulations that limit drinking water concentrations of disinfection by-products, which are formed primarily when chlorine disinfection is used, incentivize drinking water utilities to change from chlorine disinfection to monochloramine disinfection.

Infections by nontuberculous mycobacteria (NTM) are primarily acquired from environmental sources, including exposure to municipally treated drinking water. Higher levels of NTM have been reported in drinking water disinfected with monochloramine than in that disinfected with chlorine. However, the relationships between water treatment practices and NTM infection are unclear. The objective of this study was to examine a possible relationship between residual disinfectant used for municipal drinking water treatment (monochloramine or chlorine) and NTM infection. We retrospectively reviewed NTM diagnostic tests performed at a single health care center during a 15-year period. Information on municipal water treatment practices, including disinfectant and primary source water type, was obtained for 140 cities. Based on a logistic regression model, municipal drinking water disinfection with monochloramine compared to chlorine was not associated with NTM infection (P = 0.24). An additional model variable examining water source showed that the likelihood of having an NTM infection was 1.46 times higher for patients residing in cities with drinking water derived from surface water than for those residing in cities with drinking water derived from groundwater (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.03 to 2.08; P = 0.04). In an inverse propensity score weighted regression, monochloramine disinfection was also not associated with NTM infection. A moderate effect on NTM infection rates was observed in the weighted regression for municipal drinking water derived from surface water, though the results were not statistically significant (OR, 1.24; 95% CI, 0.92 to 1.69; P = 0.17).

IMPORTANCE Infections by nontuberculous mycobacteria (NTM) result in significant morbidity, mortality, and health care costs. NTM are primarily acquired from environmental sources, including exposure to municipally treated drinking water. Higher levels of NTM have been reported in drinking water disinfected with monochloramine than in drinking water disinfected with chlorine. Our results suggest that municipal drinking water disinfection with monochloramine compared to chlorine is not associated with higher risk of NTM infection. This is important given that regulations that limit drinking water concentrations of disinfection by-products, which are formed primarily when chlorine disinfection is used, incentivize drinking water utilities to change from chlorine disinfection to monochloramine disinfection.