A Waterborne Outbreak of Gastroenteritis with Multiple Etiologies among Resort Island Visitors and Residents: Ohio, 2004

Gastroenteritis Outbreaks after Contamination of Water Supply Systems: Public Health Response Gaps and Challenges, Greece, 2004-2023

BACKGROUND

waterborne disease outbreaks (WGDOs) following the contamination of drinking water remain a public health concern.

METHODS

The current study aims to assess the occurrence and identify gaps in the notification and investigation of WGDOs in Greece. Data for 2004-2023 were retrieved and summarized.

RESULTS

Thirty-five outbreaks with 6128 recorded cases were identified. The median time from the date of onset in the first cases to reporting was 7 days (range: 1-26 days). Authorities were informed by health care services in thirty (85.7%) outbreaks and by the media in five (14.3%). The investigation methods used varied. An analytical study was conducted in nine (25.7%) outbreaks and the testing of clinical samples in twenty-seven (77.1%). In three (11.1%) outbreaks, clinical samples were simultaneously tested for multiple bacteria, viruses, and parasites. Water samples were collected in nineteen (54.3%) outbreaks (in three after chlorination) with a mean time lag of 5 days (range: 1-20 days) from the first cases. A pathogen in clinical samples was identified in 20 (57.1%) outbreaks and, in 1 (6.25%), the same microorganism was isolated in both clinical and water samples.

CONCLUSIONS

delays in reporting and the heterogeneity of investigations depict that the surveillance of WGDOs and response practices should be strengthened, and operational procedures should be standardised.

Impact of sewer overflow on public health: A comprehensive scientometric analysis and systematic review

Sewer overflow (SO), which has attracted global attention, poses serious threat to public health and ecosystem. SO impacts public health via consumption of contaminated drinking water, aerosolization of pathogens, food-chain transmission, and direct contact with fecally-polluted rivers and beach sediments during recreation. However, no study has attempted to map the linkage between SO and public health including Covid-19 using scientometric analysis and systematic review of literature. Results showed that only few countries were actively involved in SO research in relation to public health. Furthermore, there are renewed calls to scale up environmental surveillance to safeguard public health. To safeguard public health, it is important for public health authorities to optimize water and wastewater treatment plants and improve building ventilation and plumbing systems to minimize pathogen transmission within buildings and transportation systems. In addition, health authorities should formulate appropriate policies that can enhance environmental surveillance and facilitate real-time monitoring of sewer overflow. Increased public awareness on strict personal hygiene and point-of-use-water-treatment such as boiling drinking water will go a long way to safeguard public health. Ecotoxicological studies and health risk assessment of exposure to pathogens via different transmission routes is also required to appropriately inform the use of lockdowns, minimize their socio-economic impact and guide evidence-based welfare/social policy interventions. Soft infrastructures, optimized sewer maintenance and prescreening of sewer overflow are recommended to reduce stormwater burden on wastewater treatment plant, curtail pathogen transmission and marine plastic pollution. Comprehensive, integrated surveillance and global collaborative efforts are important to curtail on-going Covid-19 pandemic and improve resilience against future pandemics.

Waterborne Isolates of Campylobacter jejuni Are Able to Develop Aerotolerance, Survive Exposure to Low Temperature, and Interact With Acanthamoeba polyphaga

Campylobacter jejuni is regarded as the leading cause of bacterial gastroenteritis around the world. Even though it is generally considered to be a sensitive microaerobic pathogen, it is able to survive in the environment outside of the intestinal tract of the host. This study aimed to assess the impact of selected environmental parameters on the survival of 14 C. jejuni isolates of different origins, including 12 water isolates. The isolates were tested for their antibiotic resistance, their ability to survive at low temperature (7°C), develop aerotolerance, and to interact with the potential protozoan host Acanthamoeba polyphaga. The antibiotic susceptibility was determined by standard disk diffusion according to EUCAST. Out of the 14 isolates, 8 were resistant to ciprofloxacin (CIP) and 5 to tetracycline (TET), while only one isolate was resistant to erythromycin (ERY). Five isolates were resistant to two different antibiotic classes. Tetracycline resistance was only observed in isolates isolated from wastewater and a clinical sample. Further, the isolates were tested for their survival at 7°C under both aerobic and microaerobic conditions using standard culture methods. The results showed that under microaerobic conditions, all isolates maintained their cultivability for 4 weeks without a significant decrease in the numbers of bacteria and variation between the isolates. However, significant differences were observed under aerobic conditions (AC). The incubation led to a decrease in the number of cultivable cells, with complete loss of cultivability after 2 weeks (one water isolate), 3 weeks (7 isolates), or 4 weeks of incubation (6 isolates). Further, all isolates were studied for their ability to develop aerotolerance by repetitive subcultivation under microaerobic and subsequently AC. Surprisingly, all isolates were able to adapt and grow under AC. As the last step, 5 isolates were selected to evaluate a potential protective effect provided by A. polyphaga. The cocultivation of isolates with the amoeba resulted in the survival of about 40% of cells treated with an otherwise lethal dose of gentamicin. In summary, C. jejuni is able to adapt and survive in a potentially detrimental environment for a prolonged period of time, which emphasizes the role of the environmental transmission route in the spread of campylobacteriosis.

The Persistence of Bacterial Pathogens in Surface Water and Its Impact on Global Food Safety

Water is vital to agriculture. It is essential that the water used for the production of fresh produce commodities be safe. Microbial pathogens are able to survive for extended periods of time in water. It is critical to understand their biology and ecology in this ecosystem in order to develop better mitigation strategies for farmers who grow these food crops. In this review the prevalence, persistence and ecology of four major foodborne pathogens, Shiga toxin-producing Escherichia coli (STEC), Salmonella, Campylobacter and closely related Arcobacter, and Listeria monocytogenes, in water are discussed. These pathogens have been linked to fresh produce outbreaks, some with devastating consequences, where, in a few cases, the contamination event has been traced to water used for crop production or post-harvest activities. In addition, antimicrobial resistance, methods improvements, including the role of genomics in aiding in the understanding of these pathogens, are discussed. Finally, global initiatives to improve our knowledge base of these pathogens around the world are touched upon.

'Evidence for waterborne origin of an extended mixed gastroenteritis outbreak in a town in Northern Greece, 2019'

We investigated a large gastroenteritis outbreak that occurred in Northern Greece in 2019. A case was defined as anyone presenting with diarrhoea and/or vomiting from 24 January 2019 to 04 February 2019. We conducted a case-control study (CCS) using random selection of participants >16 years of age, residents of town X, who visited the health care centre between 25 and 28 January 2019. Moreover, we conducted a retrospective cohort study (CS) at the four elementary schools of the town. We collected clinical and water samples and the water supply system was inspected. In total, we recorded 638 cases (53% female; median age was 44 years (range 0-93)). Forty-eight cases and 52 controls participated in the CCS and 236 students in the CS. Both CCS and CS indicated tap water as the most likely source (OR 10, 95% CI 2.09-93.4, explaining 95.7% of cases; RR = 2.22, 95% CI 1.42-3.46, respectively). More than one pathogen was detected from stool samples of 6 of the 11 cases tested (norovirus, Campylobacter jejuni, Enterohemorrhagic E. coli (EHEC) and Enteropathogenic E. coli (EPEC)). Water samples, collected after ad-hoc chlorination, tested negative. Technical failures of the water tanks' status were identified. Our results suggested a waterborne outbreak. We recommended regular monitoring of the water supply system and immediate repair of technical failures.

Determining the primary sources of fecal pollution using microbial source tracking assays combined with land-use information in the Edwards Aquifer

The Edwards Aquifer serves as a primary source of drinking water to more than 2 million people in south-central Texas, and as a karst aquifer, is vulnerable to human and animal fecal contamination which poses a serious risk to human and environmental health. A one-year study (Jan 2018 - Feb 2019) was conducted to determine the primary sources of fecal pollution along the Balcones and Leon Creek within the Edwards Aquifer recharge and contributing zones using general (E. coli, enterococci, and universal Bacteriodales) and host-associated (human-, dog-, cow- and chicken/duck-associated Bacteriodales) microbial source tracking (MST) assays. Additionally, sites were classified based on surrounding land use as a potential source predictor and marker levels were correlated with rain events and water quality parameters. Levels for the three general indicators were highest and exhibited similar trends across the sampling sites, suggesting that the sole use of these markers is not sufficient for specific fecal source identification. Among the host-associated markers, highest concentrations were observed for the dog marker (BacCan) in the Leon Creek area and the cow marker (BacCow) in the Balcones Creek area. Additionally, Chicken/Duck-Bac, BacCan and BacCow all exhibited higher concentrations during the spring season and the end of fall/early winter. Relatively lower concentrations were observed for the human-associated markers (HF183 and BacHum), however, levels were higher in the Leon Creek area and highest following rainfall events. Additionally, relatively higher levels in HF183 and BacHum were observed at sites having greater human population and septic tank density and may be attributed to leaks or breaks in these infrastructures. This study is the first to examine and compare fecal contamination at rural and urban areas in the recharge and contributing zones of the Edwards Aquifer using a molecular MST approach targeting Bacteroidales 16S rRNA gene-based assays. The Bacteroidales marker assays, when combined with land use and weather information, can allow for a better understanding of the sources and fluxes of fecal contamination, which can help devise effective mitigation measures to protect water quality.

Cryptosporidium spp. in groundwater supplies intended for human consumption - A descriptive review of global prevalence, risk factors and knowledge gaps

Cryptosporidiosis is one of the leading causes of diarrhoeal illness and mortality induced by protozoan pathogens worldwide. As a largely waterborne disease, emphasis has been given to the study of Cryptosporidium spp. in surface waters, readily susceptible to pathogenic contamination. Conversely, the status of Cryptosporidium in potable groundwater sources, generally regarded as a pristine and "safe" drinking-water supply owing to (sub)-soil protection, remains largely unknown. As such, this investigation presents the first literature review aimed to ascertain the global prevalence of Cryptosporidium in groundwater supply sources intended for human consumption. Thirty-seven peer-reviewed studies were identified and included in the review. Groundwater sample and supply detection rates (estimated 10-20%) indicate Cryptosporidium is frequently present in domestic groundwater sources, representing a latent health concern for groundwater consumers. Specifically, sample (10.4%) and source (19.1%) detection rates deriving from comprehensive "temporal" investigations are put forward as representative of a contamination 'baseline' for Cryptosporidium in 'domestic' groundwater supplies. Proposed 'baseline' prevalence figures are largely applicable in preventive risk-based catchment and groundwater quality management including the formulation of Quantitative Microbial Risk Assessment (QMRA). Notwithstanding, a large geographical disparity in available investigations and lack of standardized reporting restrict the transferability of research findings. Overall, the mechanisms responsible for Cryptosporidium transport and ingress into groundwater supplies remain ambiguous, representing a critical knowledge gap, and denoting a distinctive lack of integration between groundwater and public-health sub-disciplines among investigations. Key recommendations and guidelines are provided for prospective studies directed at more integrative and multi-disciplinary research.

The NSERC Canadian Lake Pulse Network: A national assessment of lake health providing science for water management in a changing climate

The distribution and quality of water resources vary dramatically across Canada, and human impacts such as land-use and climate changes are exacerbating uncertainties in water supply and security. At the national level, Canada has no enforceable standards for safe drinking water and no comprehensive water-monitoring program to provide detailed, timely reporting on the state of water resources. To provide Canada's first national assessment of lake health, the NSERC Canadian Lake Pulse Network was launched in 2016 as an academic-government research partnership. LakePulse uses traditional approaches for limnological monitoring as well as state-of-the-art methods in the fields of genomics, emerging contaminants, greenhouse gases, invasive pathogens, paleolimnology, spatial modelling, statistical analysis, and remote sensing. A coordinated sampling program of about 680 lakes together with historical archives and a geomatics analysis of over 80,000 lake watersheds are used to examine the extent to which lakes are being altered now and in the future, and how this impacts aquatic ecosystem services of societal importance. Herein we review the network context, objectives and methods.

Extreme Precipitation, Public Health Emergencies, and Safe Drinking Water in the USA

PURPOSE OF REVIEW

This review examines the effectiveness of drinking water regulations to inform public health during extreme precipitation events. This paper estimates the vulnerability of specific populations to flooding in their public water system, reviews the literature linking precipitation to waterborne outbreaks, examines the role that Safe Drinking Water Act and Public Notification (PN) Rule have in public health emergencies, and reviews the effectiveness of the PN Rule during the 2017 Hurricane Maria in Puerto Rico.

RECENT FINDINGS

Public water systems in large metropolitan areas have substantial portions of their customer base at risk for a waterborne outbreak during a flooding event. The PN Rule are ambiguous for who is responsible for declaring a "waterborne emergency" following a natural disaster like Hurricane Maria. Revisions to the current PN Rule that mandate public notification and water quality sampling during extreme precipitation events are necessary to ensure the public is aware of their drinking water quality following these events.

Occurrence of Legionella in groundwater used for sprinkler irrigation in Southern Italy

Legionellae are opportunistic bacteria that cause various conditions after exposure to contaminated aerosols, ranging from a serious type of pneumonia to a mild case of an influenza-like illness. Despite the risks of exposure, little is known about the occurrence of Legionella in natural environments and, even though studies have shown that there is a potential risk of transmission via inhalation, it does not have to be detected in groundwater that is used for irrigation. The culture methods traditionally used to detect Legionella have several limits that can be partly solved by applying molecular techniques. Samples from 177 wells in Apulia, Southern Italy, were collected twice, in winter and in summer, and analyzed. When compared with the guidelines, 145 (81.9%) of the sampled wells were suitable for irrigation use. The culture-based method highlighted the presence of different species and serogroups of Legionella in 31 (21.2%) of the 145 wells that were shown to be suitable for irrigation use. A greater number of wells returned positive results for Legionella in summer than in winter (p = 0.023), and the median concentrations were mostly higher in summer (500 CFU/L) than in winter (300 CFU/L). The median temperature in the Legionella positive well waters was significantly higher than that in the negative ones, both in winter and in summer (p < 0.001). Using molecular techniques, Legionella non-pneumophila was found in 37 of the 114 wells earlier detected as suitable for irrigation use but negative for Legionella by the culture-based methods. The distribution of Legionella differ significantly in porous aquifers compared to the karst-fissured ones both with quantitative polymerase chain reaction (qPCR) (p = 0.0004) and viable cells by propidium monoazide (PMA-qPCR) (p = 0.0000). Legionella concentrations were weakly correlated with temperature of water both with qPCR (ρ = 0.47, p = 0.0033) and PMA-qPCR (ρ = 0.41, p = 0.0126). Our data suggest that water that aerosolizes when sprinkled on plants represents a potential source of Legionellosis, with a higher risk from exposure in summer. On a practical level, this finding is important for workers (farmers and gardeners) who are in contact with waters used for irrigation.

Non-potable use of Lisbon underground water: microbiological and hydrochemical data from a 4-year case study

Mitigation of global warming scenarios by the United Nations Economic Commission for Europe (UNECE) water convention requires better water use policies by all management parties. One of Lisbon's municipal contributions to target a sustainable urban water cycle has been to assess the microbial and hydrochemical quality of groundwater. The aim is to clarify the possible existence of contaminations and respective sources, seasonality, and to assess non-drinking alternative uses of those waters. To this respect, five water sources over a 4-year period were monitored for physical, chemical, and microbial parameters (temperature, pH, NO₂^-, NO₃^-, NO₄^-, oxidability, conductivity, total hardness, Escherichia coli, total coliforms, enterococci, and heterotrophic plate count at 22 °C and 37 °C). The results show mean values of physical and chemical parameters within the WHO and national drinking water guidelines and regulations. However, microbial parameters exceed these limits, showing no seasonality. Microbial contamination may not necessarily imply the uselessness of groundwater for uses other than for drinking. For routine water quality assessment, a selection of a more adequate group of microbiological indicators is necessary, in order to evaluate potential public health risks, regarding the use of the identified water sources for non-potable purposes like irrigation or street cleaning. This approach is being promoted by the UNECE's protocol for water and health, article 6, 2 (i); in accordance with the scope of the UN's sustainable goals.

Investigation using whole genome sequencing of a prolonged restaurant outbreak of Salmonella Typhimurium linked to the building drainage system, England, February 2015 to March 2016

Following notification of a Salmonella enterica serovar Typhimurium gastroenteritis outbreak, we identified 82 cases linked to a restaurant with symptom onset from 12 February 2015 to 8 March 2016. Seventy-two cases had an isolate matching the nationally unique whole genome sequencing profile (single nucleotide polymorphism (SNP) address: 1.1.1.124.395.395). Interviews established exposure to the restaurant and subsequent case-control analysis identified an association with eating carvery buffet food (adjusted odds ratios (AOR): 20.9; 95% confidence interval (CI): 2.2 - ∞). Environmental inspections, food/water testing, and a food trace-back investigation were inconclusive. Repeated cycles of cleaning were undertaken, including hydrogen peroxide fogging, however, transmission continued. After 7 months of investigation, environmental swabbing identified 106 isolates from kitchen surfaces and restaurant drains matching the outbreak profile. We found structural faults with the drainage system and hypothesised that a reservoir of bacteria in drain biofilm and underfloor flooded areas may have sustained this outbreak. Ineffective drain water-traps (U-bends) may have also contributed by allowing transmission of contaminated aerosols into the kitchen environment. These findings suggest that routine swabbing of sink drain points and inspection of drainage systems should be considered in future outbreak scenarios.

Phenotypic and Transcriptomic Responses of Campylobacter jejuni Suspended in an Artificial Freshwater Medium

Campylobacter jejuni is the leading cause of campylobacteriosis in the developed world. Although most cases are caused by consumption of contaminated meat, a significant proportion is linked to ingestion of contaminated water. The differences between C. jejuni strains originating from food products and those isolated from water are poorly understood. Working under the hypothesis that water-borne C. jejuni strains are better equipped at surviving the nutrient-poor aquatic environment than food-borne strains, the present study aims to characterize these differences using outbreak strains 81116 and 81-176. Strain 81116 caused a campylobacteriosis outbreak linked to consumption of water, while strain 81-176 was linked to consumption of raw milk. CFU counts and viability assays showed that 81116 survives better than 81-176 at 4°C in a defined freshwater medium (Fraquil). Moreover, 81116 was significantly more resistant to oxidative stress and bile salt than strain 81-176 in Fraquil. To better understand the genetic response of 81116 to water, a transcriptomic profiling study was undertaken using microarrays. Compared to rich broth, strain 81116 represses genes involved in amino acid uptake and metabolism, as well as genes involved in costly biosynthetic processes such as replication, translation, flagellum synthesis and virulence in response to Fraquil. In accordance with the observed increase in stress resistance in Fraquil, 81116 induces genes involved in resistance to oxidative stress and bile salt. Interestingly, genes responsible for cell wall synthesis were also induced upon Fraquil exposure. Finally, twelve unique genes were expressed in Fraquil; however, analysis of their distribution in animal and water isolates showed that they are not uniquely and ubiquitously present in water isolates, and thus, unlikely to play a major role in adaptation to water. Our results show that some C. jejuni strains are more resilient than others, thereby challenging current water management practices. The response of 81116 to Fraquil serves as a starting point to understand the adaptation of C. jejuni to water and its subsequent transmission.

Safe drinking water and waterborne outbreaks

The present work compiles a review on drinking waterborne outbreaks, with the perspective of production and distribution of microbiologically safe water, during 2000-2014. The outbreaks are categorised in raw water contamination, treatment deficiencies and distribution network failure. The main causes for contamination were: for groundwater, intrusion of animal faeces or wastewater due to heavy rain; in surface water, discharge of wastewater into the water source and increased turbidity and colour; at treatment plants, malfunctioning of the disinfection equipment; and for distribution systems, cross-connections, pipe breaks and wastewater intrusion into the network. Pathogens causing the largest number of affected consumers were Cryptosporidium, norovirus, Giardia, Campylobacter, and rotavirus. The largest number of different pathogens was found for the treatment works and the distribution network. The largest number of affected consumers with gastrointestinal illness was for contamination events from a surface water source, while the largest number of individual events occurred for the distribution network.

Shifting white pox aetiologies affecting Acropora palmata in the Florida Keys, 1994-2014

We propose 'the moving target hypothesis' to describe the aetiology of a contemporary coral disease that differs from that of its historical disease state. Hitting the target with coral disease aetiology is a complex pursuit that requires understanding of host and environment, and may lack a single pathogen solution. White pox disease (WPX) affects the Caribbean coral Acropora palmata. Acroporid serratiosis is a form of WPX for which the bacterial pathogen (Serratia marcescens) has been established. We used long-term (1994-2014) photographic monitoring to evaluate historical and contemporary epizootiology and aetiology of WPX affecting A. palmata at eight reefs in the Florida Keys. Ranges of WPX prevalence over time (0-71.4%) were comparable for the duration of the 20-year study. Whole colony mortality and disease severity were high in historical (1994-2004), and low in contemporary (2008-2014), outbreaks of WPX. Acroporid serratiosis was diagnosed for some historical (1999, 2003) and contemporary (2012, 2013) outbreaks, but this form of WPX was not confirmed for all WPX cases. Our results serve as a context for considering aetiology as a moving target for WPX and other coral diseases for which pathogens are established and/or candidate pathogens are identified. Coral aetiology investigations completed to date suggest that changes in pathogen, host and/or environment alter the disease state and complicate diagnosis.

Gastroenteritis Outbreaks Associated with the Emergence of the New GII.4 Sydney Norovirus Variant during the Epidemic of 2012/13 in Shenzhen City, China

Noroviruses (NoVs) are the leading cause of gastroenteritis outbreaks in humans worldwide. Since late 2012, a new GII.4 variant Sydney 2012 has caused a significant increase in NoV epidemics in several countries. From November of 2012 to January of 2013, three gastroenteritis outbreaks occurred in two social welfare homes (Outbreaks A and B) and a factory (Outbreak C) in Shenzhen city of China. Feces and swabs were collected for laboratory tests for causative agents. While no bacterial pathogen was identified, all three outbreaks were caused by NoVs with detection rates of 26.2% (16/61) at Outbreak A, 35.2% (38/108) at Outbreak B), and 59.3% (16/27) at Outbreaks C. For Outbreak B, 25 of the 29 symptomatic individuals (86.2%) and 13 of the 79 asymptomatic individuals (16.5%) were found NoV-positive. For Outbreak C, an asymptomatic food handler was NoV-positive. All thirteen NoV sequences from the three outbreaks were classified into genogroup II and genotype 4 (GII.4), which we identified to be the GII.4 Sydney 2012 variant. The genome of two isolates from Outbreaks A and B were recombinant with the opening reading frame (ORF) 1 of GII.4 Osaka 2007 and ORF2 and 3 of the GII.4 New Orleans. Our study indicated that the GII.4 Sydney 2012 variant emerged and caused the outbreaks in China.

Microbiological and hydrogeological assessment of groundwater in southern Italy

This study represents the first investigation of microbiological groundwater pollution as a function of aquifer type and season for the Apulia region of southern Italy. Two hundred and seven wells were randomly selected from those monitored by the Regional Agency for Environmental Protection for emergency use. Both compulsory (Escherichia coli, Total Coliform, and Enterococci) and optional (Pseudomonas aeruginosa, Salmonella spp., Heterotrophic Plate Count at 37 and 22 °C) microbiological parameters were assessed regularly at these wells. Groundwater from only 18 of the 207 (8.7 %) wells was potable; these all draw from karst-fissured aquifers. The remaining 189 wells draw from karst-fissured (66.1 %) or porous (33.9 %) aquifers. Of these, 82 (43.4 %) tested negative for Salmonella spp. and P. aeruginosa, while 107 (56.6 %) tested positive for P. aeruginosa (75.7 %), Salmonella spp. (10.3 %), or for both Salmonella spp. and P. aeruginosa (14 %). A logistic regression model shows that the probability of potable groundwater depends on both season and aquifer type. Typically, water samples were more likely to be potable in autumn-winter than in spring-summer periods (odds ratio, OR = 2.1; 95 % confidence interval, 95 % CI = 1.6-2.7) and from karst-fissured rather than porous aquifers (OR = 5.8; 95 % CI = 4.4-7.8). Optional parameters only showed a seasonal pattern (OR = 2.6; 95 % CI = 1.7-3.9). Clearly, further investigation of groundwater microbiological aspects should be carried out to identify the risks of fecal contamination and to establish appropriate protection methods, which take into account the hydrogeological and climatic characteristics of this region.

Non food-related risk factors of campylobacteriosis in Canada: a matched case-control study

BACKGROUND

Campylobacteriosis is a prominent bacterial gastrointestinal infection worldwide with several transmission pathways. Its non-foodborne routes have been less documented and quantified. The study aimed to quantitatively explore the role of potential risk factors not directly associated with food for sporadic cases of C. jejuni infection in Canada.

METHODS

This retrospective matched case-control study was built on an enhanced campylobacteriosis surveillance system and on a survey of healthy people and their behaviour with regards to potential risk factors for gastrointestinal infections that occurred in the same area in Canada. Eighty-five cases were individually matched by age and season to 170 controls.

RESULTS

Through conditional logistic regression, risk factors were found only among water-related factors (drinking untreated water, using tap filter, drinking water from well and swimming in natural water), whereas drinking bottled water was protective. Among the 32 non-water related factors explored, 12 were surprisingly 'protective' factors without relevant explanation for that effect (for example gardening, attending a barbecue, eating food from a fast-food restaurant), suggesting that human infection by Campylobacter may be more frequently acquired at home than outside the home.

CONCLUSIONS

This study confirms and quantifies the importance of the waterborne transmission of campylobacteriosis. People are encouraged to drink only treated water and to avoid the ingestion of natural water as much as possible while swimming or playing in water. Globally, general hygiene and proper food handling and cooking practices at home should continue to be encouraged.

Quantifying potential sources of surface water contamination with Campylobacter jejuni and Campylobacter coli

Campylobacter is the most common causative agent of human bacterial gastroenteritis and is frequently found in surface water, where it indicates recent contamination with animal faeces, sewage effluent, and agricultural run-off. The contribution of different animal reservoirs to surface water contamination with Campylobacter is largely unknown. In the Netherlands, the massive poultry culling to control the 2003 avian influenza epidemic coincided with a 44-50% reduction in human campylobacteriosis cases in the culling areas, suggesting substantial environment-mediated spread of poultry-borne Campylobacter. We inferred the origin of surface water Campylobacter jejuni and Campylobacter coli strains in Luxembourg and the Netherlands, as defined by multilocus sequence typing, by comparison to strains from poultry, pigs, ruminants, and wild birds, using the asymmetric island model for source attribution. Most Luxembourgish water strains were attributed to wild birds (61.0%), followed by poultry (18.8%), ruminants (15.9%), and pigs (4.3%); whereas the Dutch water strains were mainly attributed to poultry (51.7%), wild birds (37.3%), ruminants (9.8%), and pigs (1.2%). Attributions varied over seasons and surface water types, and geographical variation in the relative contribution of poultry correlated with the magnitude of poultry production at either the national or provincial level, suggesting that environmental dissemination of Campylobacter from poultry farms and slaughterhouses can be substantial in poultry-rich regions.

Untangling the Impacts of Climate Change on Waterborne Diseases: a Systematic Review of Relationships between Diarrheal Diseases and Temperature, Rainfall, Flooding, and Drought

Global climate change is expected to affect waterborne enteric diseases, yet to date there has been no comprehensive, systematic review of the epidemiological literature examining the relationship between meteorological conditions and diarrheal diseases. We searched PubMed, Embase, Web of Science, and the Cochrane Collection for studies describing the relationship between diarrheal diseases and four meteorological conditions that are expected to increase with climate change: ambient temperature, heavy rainfall, drought, and flooding. We synthesized key areas of agreement and evaluated the biological plausibility of these findings, drawing from a diverse, multidisciplinary evidence base. We identified 141 articles that met our inclusion criteria. Key areas of agreement include a positive association between ambient temperature and diarrheal diseases, with the exception of viral diarrhea and an increase in diarrheal disease following heavy rainfall and flooding events. Insufficient evidence was available to evaluate the effects of drought on diarrhea. There is evidence to support the biological plausibility of these associations, but publication bias is an ongoing concern. Future research evaluating whether interventions, such as improved water and sanitation access, modify risk would further our understanding of the potential impacts of climate change on diarrheal diseases and aid in the prioritization of adaptation measures.

Survival in water of Campylobacter jejuni strains isolated from the slaughterhouse

Campylobacter jejuni cause gastroenteritis in humans. The main transmission vector is the consumption or handling of contaminated chicken meat, since chicken can be colonized asymptomatically by C. jejuni. However, water has been implicated as the transmission vector in a few outbreaks. One possibility is the contamination of water effluent by C. jejuni originating from chicken farm. The ability of C. jejuni to be transmitted by water would be closely associated to its ability to survive in water. Therefore, in this study, we have evaluated the ability of reference strains and chicken-isolated strains to survive in water. Defined water media were used, since the composition of tap water is variable. We showed that some isolates survive better than others in defined freshwater (Fraquil) and that the survival was affected by temperature and the concentration of NaCl. By comparing the ability of C. jejuni to survive in water with other phenotypic properties previously tested, we showed that the ability to survive in water was negatively correlated with autoagglutination. Our data showed that not all chicken isolates have the same ability to survive in water, which is probably due to difference in genetic content.

Communitywide cryptosporidiosis outbreak associated with a surface water-supplied municipal water system--Baker City, Oregon, 2013

Cryptosporidium, a parasite known to cause large drinking and recreational water outbreaks, is tolerant of chlorine concentrations used for drinking water treatment. Human laboratory-based surveillance for enteric pathogens detected a cryptosporidiosis outbreak in Baker City, Oregon during July 2013 associated with municipal drinking water. Objectives of the investigation were to confirm the outbreak source and assess outbreak extent. The watershed was inspected and city water was tested for contamination. To determine the community attack rate, a standardized questionnaire was administered to randomly sampled households. Weighted attack rates and confidence intervals (CIs) were calculated. Water samples tested positive for Cryptosporidium species; a Cryptosporidium parvum subtype common in cattle was detected in human stool specimens. Cattle were observed grazing along watershed borders; cattle faeces were observed within watershed barriers. The city water treatment facility chlorinated, but did not filter, water. The community attack rate was 28·3% (95% CI 22·1-33·6), sickening an estimated 2780 persons. Watershed contamination by cattle probably caused this outbreak; water treatments effective against Cryptosporidium were not in place. This outbreak highlights vulnerability of drinking water systems to pathogen contamination and underscores the need for communities to invest in system improvements to maintain multiple barriers to drinking water contamination.

Microbial indicators, pathogens and methods for their monitoring in water environment

Water is critical for life, but many people do not have access to clean and safe drinking water and die because of waterborne diseases. The analysis of drinking water for the presence of indicator microorganisms is key to determining microbiological quality and public health safety. However, drinking water-related illness outbreaks are still occurring worldwide. Moreover, different indicator microorganisms are being used in different countries as a tool for the microbiological examination of drinking water. Therefore, it becomes very important to understand the potentials and limitations of indicator microorganisms before implementing the guidelines and regulations designed by various regulatory agencies. This review provides updated information on traditional and alternative indicator microorganisms with merits and demerits in view of their role in managing the waterborne health risks as well as conventional and molecular methods proposed for monitoring of indicator and pathogenic microorganisms in the water environment. Further, the World Health Organization (WHO) water safety plan is emphasized in order to develop the better approaches designed to meet the requirements of safe drinking water supply for all mankind, which is one of the major challenges of the 21st century.

Preventing community-wide transmission of Cryptosporidium: a proactive public health response to a swimming pool-associated outbreak--Auglaize County, Ohio, USA

The incidence of recreational water-associated outbreaks in the United States has significantly increased, driven, at least in part, by outbreaks both caused by Cryptosporidium and associated with treated recreational water venues. Because of the parasite's extreme chlorine tolerance, transmission can occur even in well-maintained treated recreational water venues (e.g. pools) and a focal cryptosporidiosis outbreak can evolve into a community-wide outbreak associated with multiple recreational water venues and settings (e.g. childcare facilities). In August 2004 in Auglaize County, Ohio, multiple cryptosporidiosis cases were identified and anecdotally linked to pool A. Within 5 days of the first case being reported, pool A was hyperchlorinated to achieve 99·9% Cryptosporidium inactivition. A case-control study was launched to epidemiologically ascertain the outbreak source 11 days later. A total of 150 confirmed and probable cases were identified; the temporal distribution of illness onset was peaked, indicating a point-source exposure. Cryptosporidiosis was significantly associated with swimming in pool A (matched odds ratio 121·7, 95% confidence interval 27·4-∞) but not with another venue or setting. The findings of this investigation suggest that proactive implementation of control measures, when increased Cryptosporidium transmission is detected but before an outbreak source is epidemiologically ascertained, might prevent a focal cryptosporidiosis outbreak from evolving into a community-wide outbreak.

Association of host, agent and environment characteristics and the duration of incubation and symptomatic periods of norovirus gastroenteritis

We analysed the reported duration of incubation and symptomatic periods of norovirus for a dataset of 1022 outbreaks, 64 of which reported data on the average incubation period and 87 on the average symptomatic period. We found the mean and median incubation periods for norovirus to be 32·8 [95% confidence interval (CI) 30·9-34·6] hours and 33·5 (95% CI 32·0-34·0) hours, respectively. For the symptomatic period we found the mean and median to be 44·2 (95% CI 38·9-50·7) hours and 43·0 (95% CI 36·0-48·0) hours, respectively. We further investigated how these average periods were associated with several reported host, agent and environmental characteristics. We did not find any strong, biologically meaningful associations between the duration of incubation or symptomatic periods and the reported host, pathogen and environmental characteristics. Overall, we found that the distributions of incubation and symptomatic periods for norovirus infections are fairly constant and showed little differences with regard to the host, pathogen and environmental characteristics we analysed.

Influencing factors and applicability of the viability EMA-qPCR for a detection and quantification of Campylobacter cells from water samples

In recent years, increasing numbers of human campylobacteriosis cases caused by contaminated water have been reported. As the culture-based detection of Campylobacter is time consuming and can yield false-negative results, the suitability of a quantitative real-time PCR method in combination with an ethidium monoazide pretreatment of samples (EMA-qPCR) for the rapid, quantitative detection of viable Campylobacter cells from water samples was investigated. EMA-qPCR has been shown to be a promising rapid method for the detection of viable Campylobacter spp. from food samples. Application of membrane filtration and centrifugation, two methods frequently used for the isolation of bacteria from water, revealed a mean loss of up to 1.08 log10 cells/ml from spiked samples. Both methods used alone lead to a loss of dead bacteria and accumulation of viable bacteria in the sample as shown by fluorescence microscopy. After filtration of samples, no significant differences could be detected in subsequent qPCR experiments with and without EMA pretreatment compared to culture-based enumeration. High correlations (R(2)= 0.942 without EMA, R(2) = 0.893 with EMA) were obtained. After centrifugation of samples, qPCR results overestimated Campylobacter counts, whereas results from both EMA-qPCR and the reference method were comparable. As up to 81.59% of nonviable cells were detected in pond water, EMA-qPCR failed to detect correct quantities of viable cells. However, analyses of spiked tap water samples revealed a high correlation (R(2) = 0.863) between results from EMA-qPCR and the reference method. After membrane filtration, EMA-qPCR was successfully applied to Campylobacter field isolates, and results indicated an advantage over qPCR by analysing defined mixtures of viable and nonviable cells. In conclusion, EMA-qPCR is a suitable method to detect viable Campylobacter from water samples, but the isolation technique and the type/quality of the water sample impact the results.

Contributing factors to disease outbreaks associated with untreated groundwater

Disease outbreaks associated with drinking water drawn from untreated groundwater sources represent a substantial proportion (30.3%) of the 818 drinking water outbreaks reported to CDC's Waterborne Disease and Outbreak Surveillance System (WBDOSS) during 1971 to 2008. The objectives of this study were to identify underlying contributing factors, suggest improvements for data collection during outbreaks, and inform outbreak prevention efforts. Two researchers independently reviewed all qualifying outbreak reports (1971 to 2008), assigned contributing factors and abstracted additional information (e.g., cases, etiology, and water system attributes). The 248 outbreaks resulted in at least 23,478 cases of illness, 390 hospitalizations, and 13 deaths. The majority of outbreaks had an unidentified etiology (n = 135, 54.4%). When identified, the primary etiologies were hepatitis A virus (n = 21, 8.5%), Shigella spp. (n = 20, 8.1%), and Giardia intestinalis (n = 14, 5.7%). Among the 172 (69.4%) outbreaks with contributing factor data available, the leading contamination sources included human sewage (n = 57, 33.1%), animal contamination (n = 16, 9.3%), and contamination entering via the distribution system (n = 12, 7.0%). Groundwater contamination was most often facilitated by improper design, maintenance or location of the water source or nearby waste water disposal system (i.e., septic tank; n = 116, 67.4%). Other contributing factors included rapid pathogen transport through hydrogeologic formations (e.g., karst limestone; n = 45, 26.2%) and preceding heavy rainfall or flooding (n = 36, 20.9%). This analysis underscores the importance of identifying untreated groundwater system vulnerabilities through frequent inspection and routine maintenance, as recommended by protective regulations such as Environmental Protection Agency's (EPA's) Groundwater Rule, and the need for special consideration of the local hydrogeology.

Attributing foodborne salmonellosis in humans to animal reservoirs in the European Union using a multi-country stochastic model

A Bayesian modelling approach comparing the occurrence ofSalmonellaserovars in animals and humans was used to attribute salmonellosis cases to broilers, turkeys, pigs, laying hens, travel and outbreaks in 24 European Union countries.Salmonelladata for animals and humans, covering the period from 2007 to 2009, were mainly obtained from studies and reports published by the European Food Safety Authority. Availability of food sources for consumption was derived from trade and production data from the European Statistical Office. Results showed layers as the most important reservoir of human salmonellosis in Europe, with 42·4% (7 903 000 cases, 95% credibility interval 4 181 000–14 510 000) of cases, 95·9% of which was caused byS. Enteritidis. In Finland and Sweden, most cases were travel-related, while in most other countries the main sources were related to the laying hen or pig reservoir, highlighting differences in the epidemiology ofSalmonella, surveillance focus and eating habits across the European Union.

Role of environmental survival in transmission of Campylobacter jejuni

Campylobacter species are the most common cause of bacterial gastroenteritis, with C. jejuni responsible for the majority of these cases. Although it is clear that livestock, and particularly poultry, are the most common source, it is likely that the natural environment (soil and water) plays a key role in transmission, either directly to humans or indirectly via farm animals. It has been shown using multilocus sequence typing that some clonal complexes (such as ST-45) are more frequently isolated from environmental sources such as water, suggesting that strains vary in their ability to survive in the environment. Although C. jejuni are fastidious microaerophiles generally unable to grow in atmospheric levels of oxygen, C. jejuni can adapt to survival in the environment, exhibiting aerotolerance and starvation survival. Biofilm formation, the viable but nonculturable state, and interactions with other microorganisms can all contribute to survival outside the host. By exploiting high-throughput technologies such as genome sequencing and RNA Seq, we are well placed to decipher the mechanisms underlying the variations in survival between strains in environments such as soil and water and to better understand the role of environmental persistence in the transmission of C. jejuni directly or indirectly to humans.

Detecting Virus-Like Particles from the Umgeni River, South Africa

It is important to consider viruses in water quality because of their incidence as causal agents for diarrhoeal disease, and due to their characteristics, which allow them to survive in changing environmental conditions indefinitely. This study assessed the viral quality of the Umgeni River in South Africa seasonally. A two-step tangential flow filtration process was setup to remove the bacteria and to concentrate the virus populations from large volume water samples. The concentrated water samples contained up to 659 and 550 pfu/mL of somatic and F-RNA coliphages, respectively. Several virus families including Adenoviridae, Herpesviridae, Orthomyxoviridae, Picornaviridae, Poxviridae and Reoviridae were found in the river based on the morphologies examined under transmission electron microscopy. All concentrated water samples produced substantial cytopathic effects on the Vero, HEK 293, Hela and A549 cell lines. These results indicate the potential of viruses in the water samples especially from the lower catchment areas of the Umgeni River to infect human hosts throughout the year. The present study highlights the importance of routine environmental surveillance of human enteric viruses in water sources. This can contribute to a better understanding of the actual burden of disease on those who might be using the water directly without treatment.

A large waterborne gastroenteritis outbreak in central Greece, March 2012: challenges for the investigation and management

In March 2012, there was an unusual increase of gastroenteritis cases in a district with 37,264 inhabitants in central Greece. It was estimated that more than 3600 people developed symptoms. A 1:1 case-control study showed that consumption of tap water was a risk factor for acquiring infection [odds ratio (OR) 2.18, 95% confidence interval (CI) 1.11-4.28]. Descriptive data, low gastroenteritis incidence in adjacent areas with different water supply systems, and water-quality data further supported the hypothesis of a waterborne outbreak. Thirty-eight stool samples were positive for rotavirus. Bacterial indicators of recent faecal contamination were detected in samples from the water source and ice cubes from a local production enterprise. Molecular epidemiology of rotavirus strains, apart from the common strain, G3[P8], identified the unusual G/P combination G2P[8]. Water sanitation measures contributed to the control of the outbreak. This outbreak demonstrated the need for the cooperation of laboratories with different expertise and the importance of early notification of waterborne gastroenteritis outbreaks.

Concurrent infections of Giardia duodenalis, Enterocytozoon bieneusi, and Clostridium difficile in children during a cryptosporidiosis outbreak in a pediatric hospital in China

Background

Over 200 cryptosporidiosis outbreaks have been reported, but little is known if other enteric pathogens were also involved in some of these outbreaks. Recently, an outbreak of cryptosporidiosis linked to poor hygiene by two Cryptosporidium hominis subtypes occurred in a pediatric hospital ward (Ward A) in China, lasting for more than 14 months. In this study, the concurrence during the outbreak of three other enteric pathogens with a similar transmission route, Giardia duodenalis, Enterocytozoon bieneusi, and Clostridium difficile, was assessed.

Methods/Principal Findings

The occurrence of G. duodenalis, E. bieneusi, and C. difficile in 78 inpatients from Ward A and 283 and 216 inpatients from two control wards (Wards C and D) in the same hospital was examined using molecular diagnostic tools. Significantly higher infection rates were found in children in Ward A for all study pathogens than in Wards C and D (P<0.01): 9.5% versus 1.4% and 0% for G. duodenalis, 10.8% versus 2.8% and 3.7% for E. bieneusi, and 60.8% versus 37.8% and 27.8% for C. difficile, respectively. These differences were mostly seen in children ≤12 months. Enteric pathogen-positive children in Ward A (31/58 or 53.4%) were more likely to have mixed infections than those in Ward C (4/119 or 3.4%) or D (5/68, 7.4%; P<0.01). Having cryptosporidiosis was a risk factor for G. duodenalis (OR = 4.3; P = 0.08), E. bieneusi (OR = 3.1; P = 0.04), and C. difficile (OR = 4.7; P<0.01) infection. In addition, a lower diversity of G. duodenalis, E. bieneusi, and C. difficile genotypes/subtypes was observed in Ward A.

Conclusions/Significance

Data from this study suggest that multiple pathogens were concurrently present during the previous cryptosporidiosis outbreak. Examination of multiple enteric pathogens should be conducted when poor hygiene is the likely cause of outbreaks of diarrhea.

The transmission of Giardia duodenalis, Enterocytozoon bieneusi, and Clostridium difficile is poorly understood in developing countries despite their wide occurrence. Because they are transmitted by the same fecal-oral route as Cryptosporidium, in this study, we have examined the occurrence of these enteric pathogens in children during a cryptosporidiosis outbreak in a pediatric hospital in China. Using molecular diagnostic tools, we have detected significantly higher infection rates of these enteric pathogens in the outbreak ward than in two control wards in the same hospital. We have also shown a much higher occurrence of these pathogens in children having cryptosporidiosis than those having no cryptosporidiosis. We have demonstrated that the genetic diversity of enteric pathogens is much lower in the outbreak ward than in control wards. Therefore, other enteric pathogens are concurrently present during the cryptosporidiosis outbreak, and examinations for multiple enteric pathogens should be conducted when poor hygiene is considered the likely cause of outbreaks of diarrhea.

Epidemiological investigation of two parallel gastroenteritis outbreaks in school settings

BACKGROUND

Two parallel gastroenteritis outbreaks occurred in an elementary school and a neighboring kindergarten in Kilkis, Northern Greece in 2012. The aim of the study was the investigation of these two parallel outbreaks as well as their possible source.

METHODS

Two retrospective cohort studies were performed to identify the mode and the vehicle of transmission as well as the possible connection between them.

RESULTS

Elementary school and kindergarten populations of 79.9% (119/149) and 51.1% (23/45) respectively, participated in the study. Case definition was satisfied by 65 pupils from the elementary school and 14 from the kindergarten. For elementary school, 53 cases were considered primary cases of the outbreak and were included in the analysis. Based on the results of the multivariate analysis, consumption of tap water was the only statistically significant independent risk factor of gastroenteritis (RR = 2.34, 95% C.I.: 1.55-3.53).; a finding supported by the shape of the epidemic curve which referred to a common point source outbreak with secondary cases. For kindergarten, no statistically significant risk factor was identified, and the epidemic curve supported a person-to-person transmission according univariate analysis. Norovirus GI and GII and human Adenovirus were detected by Real Time PCR in stool samples from seven children of elementary school, but stool samples were not collected by children of the kindergarten.

CONCLUSIONS

Even though the etiological agent of the outbreak was not verified, combined epidemiological and laboratory results were in favor of a waterborne viral gastroenteritis outbreak at the elementary school, followed by a person to person spread at the kindergarten.

Common source outbreaks of Campylobacter infection in the USA, 1997–2008

Campylobacter is a common but decreasing cause of foodborne infections in the USA. Outbreaks are uncommon and have historically differed from sporadic cases in seasonality and contamination source. We reviewed reported outbreaks of campylobacteriosis. From 1997 to 2008, 262 outbreaks were reported, with 9135 illnesses, 159 hospitalizations, and three deaths. The annual mean was 16 outbreaks for 1997–2002, and 28 outbreaks for 2003–2008. Almost half occurred in warmer months. Foodborne transmission was reported in 225 (86%) outbreaks, water in 24 (9%), and animal contact in seven (3%). Dairy products were implicated in 65 (29%) foodborne outbreaks, poultry in 25 (11%), and produce in 12 (5%). Reported outbreaks increased during a period of declining overall incidence, and seasonality of outbreaks resembled that of sporadic infections. Unlike sporadic illnesses, which are primarily attributed to poultry, dairy products are the most common vehicle identified for outbreaks.

Enteric protozoa in the developed world: a public health perspective

Several enteric protozoa cause severe morbidity and mortality in both humans and animals worldwide. In developed settings, enteric protozoa are often ignored as a cause of diarrheal illness due to better hygiene conditions, and as such, very little effort is used toward laboratory diagnosis. Although these protozoa contribute to the high burden of infectious diseases, estimates of their true prevalence are sometimes affected by the lack of sensitive diagnostic techniques to detect them in clinical and environmental specimens. Despite recent advances in the epidemiology, molecular biology, and treatment of protozoan illnesses, gaps in knowledge still exist, requiring further research. There is evidence that climate-related changes will contribute to their burden due to displacement of ecosystems and human and animal populations, increases in atmospheric temperature, flooding and other environmental conditions suitable for transmission, and the need for the reuse of alternative water sources to meet growing population needs. This review discusses the common enteric protozoa from a public health perspective, highlighting their epidemiology, modes of transmission, prevention, and control. It also discusses the potential impact of climate changes on their epidemiology and the issues surrounding waterborne transmission and suggests a multidisciplinary approach to their prevention and control.

Giardia--from genome to proteome

In this review, the current status of genomic and proteomic research on Giardia is examined in terms of evolutionary biology, phylogenetic relationships and taxonomy. The review also describes how characterising genetic variation in Giardia from numerous hosts and endemic areas has provided a better understanding of life cycle patterns, transmission and the epidemiology of Giardia infections in humans, domestic animals and wildlife. Some progress has been made in relating genomic information to the phenotype of Giardia, and as a consequence, new information has been obtained on aspects of developmental biology and the host-parasite relationship. However, deficiencies remain in our understanding of pathogenesis and host specificity, highlighting the limitations of currently available genomic datasets.

Arcobacter in Lake Erie beach waters: an emerging gastrointestinal pathogen linked with human-associated fecal contamination

The genus Arcobacter has been associated with human illness and fecal contamination by humans and animals. To better characterize the health risk posed by this emerging waterborne pathogen, we investigated the occurrence of Arcobacter spp. in Lake Erie beach waters. During the summer of 2010, water samples were collected 35 times from the Euclid, Villa Angela, and Headlands (East and West) beaches, located along Ohio's Lake Erie coast. After sample concentration, Arcobacter was quantified by real-time PCR targeting the Arcobacter 23S rRNA gene. Other fecal genetic markers (Bacteroides 16S rRNA gene [HuBac], Escherichia coli uidA gene, Enterococcus 23S rRNA gene, and tetracycline resistance genes) were also assessed. Arcobacter was detected frequently at all beaches, and both the occurrence and densities of Arcobacter spp. were higher at the Euclid and Villa Angela beaches (with higher levels of fecal contamination) than at the East and West Headlands beaches. The Arcobacter density in Lake Erie beach water was significantly correlated with the human-specific fecal marker HuBac according to Spearman's correlation analysis (r = 0.592; P < 0.001). Phylogenetic analysis demonstrated that most of the identified Arcobacter sequences were closely related to Arcobacter cryaerophilus, which is known to cause gastrointestinal diseases in humans. Since human-pathogenic Arcobacter spp. are linked to human-associated fecal sources, it is important to identify and manage the human-associated contamination sources for the prevention of Arcobacter-associated public health risks at Lake Erie beaches.

Viral gastroenteritis associated with genogroup II norovirus among U.S. military personnel in Turkey, 2009

The present study demonstrates that multiple NoV genotypes belonging to genogroup II contributed to an acute gastroenteritis outbreak at a US military facility in Turkey that was associated with significant negative operational impact. Norovirus (NoV) is an important pathogen associated with acute gastroenteritis among military populations. We describe the genotypes of NoV outbreak occurred at a United States military facility in Turkey. Stool samples were collected from 37 out of 97 patients presenting to the clinic on base with acute gastroenteritis and evaluated for bacterial and viral pathogens. NoV genogroup II (GII) was identified by RT-PCR in 43% (16/37) stool samples. Phylogenetic analysis of a 260 base pair fragment of the NoV capsid gene from ten stool samples indicated the circulation of multiple and rare genotypes of GII NoV during the outbreak. We detected four GII.8 isolates, three GII.15, two GII.9 and a sole GII.10 NoV. Viral sequences could be grouped into four clusters, three of which have not been previously reported in Turkey. The fact that current NoV outbreak was caused by rare genotypes highlights the importance of norovirus strain typing. While NoV genogroup II is recognized as causative agent of outbreak, circulation of current genotypes has been rarely observed in large number of outbreaks.

Characterization of mono- and mixed-culture Campylobacter jejuni biofilms

Campylobacter jejuni, one of the most common causes of human gastroenteritis, is a thermophilic and microaerophilic bacterium. These characteristics make it a fastidious organism, which limits its ability to survive outside animal hosts. Nevertheless, C. jejuni can be transmitted to both humans and animals via environmental pathways, especially through contaminated water. Biofilms may play a crucial role in the survival of the bacterium under unfavorable environmental conditions. The goal of this study was to investigate survival strategies of C. jejuni in mono- and mixed-culture biofilms. We grew monoculture biofilms of C. jejuni and mixed-culture biofilms of C. jejuni with Pseudomonas aeruginosa. We found that mono- and mixed-culture biofilms had significantly different structures and activities. Monoculture C. jejuni biofilms did not consume a measurable quantity of oxygen. Using a confocal laser scanning microscope (CLSM), we found that cells from monoculture biofilms were alive according to live/dead staining but that these cells were not culturable. In contrast, in mixed-culture biofilms, C. jejuni remained in a culturable physiological state. Monoculture C. jejuni biofilms could persist under lower flow rates (0.75 ml/min) but were unable to persist at higher flow rates (1 to 2.5 ml/min). In sharp contrast, mixed-culture biofilms were more robust and were unaffected by higher flow rates (2.5 ml/min). Our results indicate that biofilms provide an environmental refuge that is conducive to the survival of C. jejuni.

Waterborne transmission of protozoan parasites: review of worldwide outbreaks - an update 2004-2010

The present update gives a comprehensive review of worldwide waterborne parasitic protozoan outbreaks that occurred and were published globally between January 2004 and December 2010. At least one hundred and ninety-nine outbreaks of human diseases due to the waterborne transmission of parasitic protozoa occurred and were reported during the time period from 2004 to 2010. 46.7% of the documented outbreaks occurred on the Australian continent, 30.6% in North America and 16.5% in Europe. Cryptosporidium spp. was the etiological agent in 60.3% (120) of the outbreaks, Giardia lamblia in 35.2% (70) and other protozoa in 4.5% (9). Four outbreaks (2%) were caused by Toxoplasma gondii, three (1.5%) by Cyclospora cayetanensis. In two outbreaks (1%) Acanthamoeba spp. was identified as the causative agent. In one outbreak, G. lamblia (in 17.6% of stool samples) and Cryptosporidium parvum (in 2.7% of stool samples) as well as Entamoeba histolytica (in 9.4% of stool samples) and Blastocystis hominis (in 8.1% of stool samples) were detected. In those countries that are likely affected most a lack of surveillance systems is noticeable. However, countries that established surveillance systems did not establish an international standardization of reporting systems.

Epidemiological characteristics and molecular typing of Salmonella enterica serovar Typhi during a waterborne outbreak in Eastern Anatolia

In this study, we aimed to study the molecular and epidemiological characteristics of Salmonella enterica serovar Typhi (S. Typhi) outbreak in Eastern Anatolia. Six hundred and thirty-seven patients from the same county with clinical diagnosis of typhoid fever were investigated with conventional methods from stool, urine and blood specimens. Antibiotic susceptibility tests and identifications were performed for positive specimens. Clonal relationships between the isolates were investigated using pulsed field gel electrophoresis (PFGE) method. A questionnaire was completed for the water consumption habits of patients. Of 91 culture positive specimens, 76 were blood, 13 were stool and 2 were urine. The isolates were resistant to ampicillin, ampicillin/sulbactam, chloramphenicol, cefuroxime, amikacin, gentamicin and trimethoprim-sulfamethoxazole. Although there was a single band difference in some isolates, PFGE results indicated that this was an outbreak caused by single strain according to the Tenover criteria. This outbreak thought to be associated with the consumption of tap water contaminated with sewage represents a breakdown of the basic public health and civil engineering infrastructure. Appropriate public health measures should be taken in order to avoid such outbreaks in the future.