A risk assessment model to evaluate the role of fecal contamination in recreational water on the incidence of cryptosporidiosis at the community level in Ontario

Developing an Integrated "Regression-QMRA method" to Predict Public Health Risks of Low Impact Developments (LIDs) for Improved Planning

Worldwide Low Impact Developments (LIDs) are used for sustainable stormwater management; however, both the stormwater and LIDs carry microbial pathogens. The widespread development of LIDs is likely to increase human exposure to pathogens and risk of infection, leading to unexpected disease outbreaks in urban communities. The risk of infection from exposure to LIDs has been assessed via Quantitative Microbial Risk Assessment (QMRA) during the operation of these infrastructures; no effort is made to evaluate these risks during the planning phase of LID treatment train in urban communities. We developed a new integrated "Regression-QMRA method" by examining the relationship between pathogens' concentration and environmental variables. Applying of this methodology to a planned LID train shows that the predicted disease burden of diarrhea from Campylobacter is highest (i.e. 16.902 DALYs/1000 persons/yr) during landscape irrigation and playing on the LID train, followed by Giardia, Cryptosporidium, and Norovirus. These results illustrate that the risk of microbial infection can be predicted during the planning phase of LID treatment train. These predictions are of great value to municipalities and decision-makers to make informed decisions and ensure risk-based planning of stormwater systems before their development.

Waterborne disease outbreaks in treated recreational water facilities: a Socio-Ecological Model perspective

Treated recreational water facilities, including swimming pools and water play parks, have often been implicated in infectious disease outbreaks. Addressing this problem is complex due to the multiple and interrelated factors contributing to outbreaks in these settings. These factors may relate to inappropriate behaviours of users and operators, lack of and inconsistent regulation of these facilities, insufficient facility maintenance, and problems associated with the design of these facilities. Given the complexity of this issue, we argue that the Socio-Ecological Model (SEM) provides a useful framework to help identify the multi-level influences and factors that have implications for designing interventions to prevent this public health problem, whilst assisting in guiding future research in this area. We apply the SEM to the current literature to help identify the influences and factors contributing to infectious disease outbreaks in treated recreational water facilities to support this argument. We also identify several gaps in the existing research that would benefit from further examination to help prevent infectious disease outbreaks in treated recreational water facilities such as public swimming pools and water play parks.

Pathogen performance testing of a natural swimming pool using a cocktail of microbiological surrogates and QMRA-derived management goals

In recent decades, natural swimming pools (NSPs) have gained popularity in Europe, especially in Germany and Austria. NSPs differ from swimming pools in that they utilize biological treatment processes based on wetland processes with no disinfection residual. However, data are missing on the specific log-reduction performance of NSPs to address enteric virus, bacteria, and parasitic protozoa removal considered necessary to meet the North American risk-based benchmark (<35 illnesses per 1,000 swimming events) set by the USEPA for voluntary swimming. In this study, we examined Canada's first NSP at Borden Park, Edmonton, Canada, to address the following three questions: (1) Given normal faecal shedding rates by bathers, what is the total log reduction (TLR) theoretically needed to meet the EPA benchmark? (2) what is the in-situ performance of the NSP based on spiking suitable microbial surrogates (MS2 coliphage, Enterococcus faecalis, and Saccharomyces cerevisiae [Baker's yeast])? and (3) how much time is required to reach acceptable bather risk levels under different representative volume-turnover rates? A reverse-quantitative microbial risk assessment (QMRA) revealed that of the four reference pathogens selected (Norovirus, Campylobacter, Cryptosporidium, and Giardia), only Norovirus was estimated to exceed the risk benchmark at the 50th, 75th, and 95th percentiles, while Campylobacter was the only other reference pathogen to exceed at the 95th percentile. Log-reduction values (LRVs) were similar to previous reports for bacterial indicators, and novel LRVs were estimated for the other two surrogates. A key finding was that more than 24 h treatment time would be necessary to provide acceptable bather protection following heavy bather use (378 bathers/day for main pool and 26 bathers/day for children's pool), due to the mixing dynamics of the treated water diluting out possible residual pool faecal contamination. The theoretical maximum number of people in the pool per day to be below USEPA's 35 gastro cases in 1,000 swimming events was 113, 47, and 8, at the 50th, 75th, and 95th percentiles. Further, the use of ultra-violet disinfection to the pool return flow had little effect on reducing the treatment time required.

Investigating the public health risks of low impact developments at residential, neighbourhood, and municipal levels

Low Impact Developments (LIDs) employ a series of vegetative techniques to retain rainfall close to the site of origin. Although LIDs offer sustainable runoff management, these infrastructures can be considered a risk to public health due to the presence of pathogens in the runoff and human exposure to contaminated water held in and transported by LIDs. The objective of this study is to examine the disease burden of Gastrointestinal illness (GI) from exposure to LIDs at the residential, neighbourhood, and municipal levels. The authors conducted a meta-analysis of literature on three water features: (1) harvested rainwater obtained from LIDs, (2) surface water, and (3) floodwater. A set of 32 studies were systematically selected to collect values of risks of infection and expressed as the disease burden, i.e. disability adjusted life years (DALYs). The results showed that the percentage of GI illness exceeding the health guidelines were high for harvested rainwater, i.e. 22% of annual disease burden exceeded the WHO guidelines (0.001 DALYs/1000 persons), and 2% exceeded the US EPA guidelines (5.75 DALYs/1000 bathers). Among the six exposures for harvested rainwater, exposure to spray irrigation, exceeded US EPA guidelines whereas; five exposures, i.e. flushing, hosing, daily shower, spray irrigation, and children playing, surpassed the WHO guidelines. Considering LID treatment, the values of annual disease burden from all the selected barriers were below US EPA guidelines however, these values exceeded the WHO guidelines for three barriers i.e. water plaza, grass swale, and open storage ponds. These findings provide a broader perspective of the disease burden associated with LIDs and emphasise to consider the type of exposures and required treatment barriers for developing LID infrastructures in urban areas.

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

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

The application of quantitative microbial risk assessment to natural recreational waters: A review

This review examines the aims of and approaches to the Quantitative Microbial Risk Assessment (QMRA) of untreated recreational waters. The literature search was conducted on four databases and yielded 54 papers, which were analyzed on a quantitative (time-trend, geographical distribution, water type) and qualitative (aims, source of microbial data, pathogens and their measurement or estimation, ways to address variability and uncertainty, sensitivity analysis) basis. In addition, the parameters, implications, and limitations were discussed for each QMRA step. Since 2003, the number of papers has greatly increased, highlighting the importance of QMRA for the risk management of recreational waters. Nevertheless, QMRA still exhibits critical issues, above all regarding contamination data and dose-response relationships. To our knowledge, this is the first review to give a wide panoramic view on QMRA in relation to recreational exposure to untreated waters. This could be useful in identifying the current knowledge gaps and research needs.

Assessing the Impact of Cyanuric Acid on Bather’s Risk of Gastrointestinal Illness at Swimming Pools

Current regulatory codes for swimming pool disinfection separately regulate free chlorine (FC) and cyanuric acid (CYA). It is well-known that CYA affects disinfection rates by reversibly binding to FC in aqueous solutions. However, limits for these regulated parameters have neither systematically accounted for this chemistry nor been based on the risk of gastrointestinal illness. This study was intended to determine the minimum concentration of FC relative to CYA based on the risk of gastrointestinal illness from normal fecal sloughing of selected pathogens and to find a simple regulatory rule for jointly managing FC and CYA for consistent disinfection. Literature data on CYA’s effect on microbial inactivation rates were reanalyzed based on the equilibria governing hypochlorous acid (HOCl) concentration. A model was developed that considers the rates of pathogen introduction into pool water, disinfection, turbulent diffusive transport, and pathogen uptake by swimmers to calculate the associated risk of illness. Model results were compared to U.S. Environmental Protection Agency (EPA) untreated recreational water acceptable gastrointestinal illness risk. For Cryptosporidium, correlation between log inactivation and Chick–Watson Ct was far better when C refers to HOCl concentration than to FC (r = −0.96 vs. −0.06). The HOCl concentration had a small variation (± 1.8%) at a constant CYA/FC ratio for typical FC and CYA ranges in swimming pools. In 27 U.S. states, the allowed FC and CYA results in HOCl concentrations spanning more than a factor of 500. Using conservative values for a high bather load pool with 2 mg/L FC and 90 mg/L CYA, the model predicted a 0.071 annual probability of infection for Giardia, exceeding the EPA regulatory 0.036 limit for untreated recreational waters. FC and CYA concentrations in swimming pools should be jointly regulated as a ratio. We recommend a maximum CYA/FC ratio of 20.

Faecal contamination in public pools in Barcelona province: Cryptosporidium spp. and bacterial indicators

A study was conducted of the occurrence of Cryptosporidium in indoor heated public swimming pools and of three bacterial indicators (Escherichia coli, faecal enterococci and Clostridium perfringens) on pool surrounds. Although all examined pools adhered strictly to the Spanish regulations, the influence of several parameters related to water conditions, pool structure, users and location on the presence of protozoa and bacteria was analysed. Cryptosporidium was detected in 18.8% of pools in 60% of the five towns studied. The maximum concentration was 13 oocysts/L in one swimming pool and one Jacuzzi. The bacterial indicators' prevalence on pool surrounds was higher than 50%, being present in all of the towns. Plastic surfaces presented the lowest bacterial prevalence, whereas painted surfaces were 100% positive. No differences were observed for pool surrounds with autonomous or disabled users. Risk of cryptosporidiosis in pool vessels indicated that concentrations over 1 oocyst/10 L enhance the risk of infection, even in one exposure. Guidelines for managing faecal accidents and public information on the importance of good hygiene behaviours in and around swimming pools are recommended to limit oocysts' presence.

Occurrence, genotyping, and health risk of Cryptosporidium and Giardia in recreational lakes in Tianjin, China

Cryptosporidium and Giardia are critical parasites in the etiology of diarrhea worldwide, and often cause waterborne outbreaks. The presence of Cryptosporidium and Giardia in recreational lakes was investigated with molecular characterization, and a comprehensive quantitative microbial risk assessment (QMRA) of protozoan infections was performed, considering multiple exposure pathways, differences in age, sex, and disease severity, and the genotypes of the protozoa. Forty-three (82.7%) and 51 (98.1%) water samples were positive for Cryptosporidium oocysts and Giardia cysts, respectively, with average counts of 3.65 oocysts/10 L and 12.58 cysts/10 L, respectively. Six Cryptosporidium species and three Giardia lamblia assemblages were confirmed with molecular analyses. The protozoan concentration was significantly associated with water turbidity, but not with the total coliform numbers. Swimming in the lakes entailed the highest incidence risk of 5.72 × 10^-4 per person per year (pppy) (95% confidence interval (CI): 0.03-43.33 × 10^-4) for Cryptosporidium and 4.04 × 10^-4 pppy (95% CI: 0.01-32.66 × 10^-4) for Giardia, whereas wading entailed the lowest risk (2.20 × 10^-4 and 1.70 × 10^-4 pppy, respectively). The annual burdens attributable to recreational-water-associated cryptosporidiosis and giardiasis were 3.44 (95% CI: 0.04-23.51) and 1.81 (95% CI: 0.01-12.96) disability-adjusted life years per 1,000,000 individuals per year, respectively. Children were more likely to have an individual disease burden than adults, and males were more likely than females. Sensitivity analysis highlighted the great importance of controlling the proportion of exposed individuals and reducing the frequency of exposure. The methodology and results of this study will allow us to better evaluate and reduce the burden of Cryptosporidium and/or Giardia infections associated with recreational water use in China and other countries.

Quantifying the Relative Contributions of Environmental Sources to the Microbial Community in an Urban Stream under Dry and Wet Weather Conditions

Investigating sources of microbial contamination in urban streams, especially when there are no contributions from combined sewer overflows or sewage effluent discharges, can be challenging. The objectives of this study were to identify the sources of microbes in an urban stream and quantify their relative contributions to the microbial community in the stream under dry and wet weather conditions. A microbial source tracking method relying on the 16S rRNA gene was used to investigate the microbial communities in water samples of an urban stream (i.e., from 11 dry and 6 wet weather events), as well as in streambed sediment, soils, street sweepings, sanitary sewage, an upstream lake, and feces of animals and birds collected between 2013 and 2015. The results showed that the Escherichia coli levels in the stream were significantly higher in wet weather flow than in dry weather flow. The upstream lake contributed approximately 93% of the microbes in dry weather flows. Water discharged from storm drain outfalls was the biggest source of microbes in wet weather flows, with a median contribution of approximately 90% in the rising limb and peak flow and about 75% in the declining limb of storms. Furthermore, about 70 to 75% of the microbes in the storm drain outfall water came from materials washed off from the street surfaces in the watershed. Fecal samples did not appear to contribute substantially to the microbes in environmental samples. The results highlight the significance of street surfaces in contributing microbial loads to urban streams under wet weather conditions.IMPORTANCE Identifying the sources of microbial contamination is important for developing best management practices to protect the water quality of urban streams for recreational uses. This study collected a large number of water samples from an urban stream under both dry and wet weather conditions and provided quantitative information on the relative contributions of various environmental compartments to the overall microbial contamination in the stream under the two weather conditions. The watershed in this study represents urban watersheds where no dominant fecal sources are consistently present. The findings highlight the importance of reducing the direct contribution of microbes from street surfaces in the watershed to urban streams under wet weather conditions. The methods and findings from this study are expected to be useful to stormwater managers and regulatory agencies.

Distribution of human-specific bacteroidales and fecal indicator bacteria in an urban watershed impacted by sewage pollution, determined using RNA- and DNA-based quantitative PCR assays

The identification of fecal pollution sources is commonly carried out using DNA-based methods. However, there is evidence that DNA can be associated with dead cells or present as "naked DNA" in the environment. Furthermore, it has been shown that rRNA-targeted reverse transcription-quantitative PCR (RT-qPCR) assays can be more sensitive than rRNA gene-based qPCR assays since metabolically active cells usually contain higher numbers of ribosomes than quiescent cells. To this end, we compared the detection frequency of host-specific markers and fecal bacteria using RNA-based RT-qPCR and DNA-based qPCR methods for water samples collected in sites impacted by combined sewer overflows. As a group, fecal bacteria were more frequently detected in most sites using RNA-based methods. Specifically, 8, 87, and 85% of the samples positive for general enterococci, Enterococcus faecalis, and Enterococcus faecium markers, respectively, were detected using RT-qPCR, but not with the qPCR assay counterpart. On average, two human-specific Bacteroidales markers were not detected when using DNA in 12% of the samples, while they were positive for all samples when using RNA (cDNA) as the template. Moreover, signal intensity was up to three orders of magnitude higher in RT-qPCR assays than in qPCR assays. The human-specific Bacteroidales markers exhibited moderate correlation with conventional fecal indicators using RT-qPCR results, suggesting the persistence of nonhuman sources of fecal pollution or the presence of false-positive signals. In general, the results from this study suggest that RNA-based assays can increase the detection sensitivity of fecal bacteria in urban watersheds impacted with human fecal sources.

Health risk assessment of exposure to organic matter from the use of reclaimed water in toilets

To estimate the carcinogenic and non-carcinogenic risks of six volatile organic compounds (VOCs) found in reclaimed water used for flushing toilets, a probabilistic health risk assessment based on Monte Carlo simulations was used. Before Monte Carlo simulations, the contaminant volatilization model was applied to estimate the concentration of the pollutants in air. Moreover, a questionnaire was used to acquire daily exposure time and the Batch Fit tool of Crystal Ball software was applied to find the best-fitting distribution of a part of the input parameters. The risk analysis indicated that the health risks from six VOCs were lower than the negligible risk level (1 × 10(-8)) in all cases, and the health risk for females was slightly higher than that for males. Overall, exposure to organic pollutants in reclaimed water during toilet flushing does not currently pose a significant carcinogenic risk to humans. In this study, we want to provide some information on the health risk from reclaimed water used for toilet flushing in China and hope that it will be useful to promote the application of reclaimed water in water-deficient areas.

Spatiotemporal analysis of Cryptosporidium species/genotypes and relationships with other zoonotic pathogens in surface water from mixed-use watersheds

Nearly 690 raw surface water samples were collected during a 6-year period from multiple watersheds in the South Nation River basin, Ontario, Canada. Cryptosporidium oocysts in water samples were enumerated, sequenced, and genotyped by detailed phylogenetic analysis. The resulting species and genotypes were assigned to broad, known host and human infection risk classes. Wildlife/unknown, livestock, avian, and human host classes occurred in 21, 13, 3, and <1% of sampled surface waters, respectively. Cryptosporidium andersoni was the most commonly detected livestock species, while muskrat I and II genotypes were the most dominant wildlife genotypes. The presence of Giardia spp., Salmonella spp., Campylobacter spp., and Escherichia coli O157:H7 was evaluated in all water samples. The greatest significant odds ratios (odds of pathogen presence when host class is present/odds of pathogen presence when host class is absent) for Giardia spp., Campylobacter spp., and Salmonella spp. in water were associated, respectively, with livestock (odds ratio of 3.1), avian (4.3), and livestock (9.3) host classes. Classification and regression tree analyses (CART) were used to group generalized host and human infection risk classes on the basis of a broad range of environmental and land use variables while tracking cooccurrence of zoonotic pathogens in these groupings. The occurrence of livestock-associated Cryptosporidium was most strongly related to agricultural water pollution in the fall (conditions also associated with elevated odds ratios of other zoonotic pathogens occurring in water in relation to all sampling conditions), whereas wildlife/unknown sources of Cryptosporidium were geospatially associated with smaller watercourses where urban/rural development was relatively lower. Conditions that support wildlife may not necessarily increase overall human infection risks associated with Cryptosporidium since most Cryptosporidium genotypes classed as wildlife in this study (e.g., muskrat I and II genotype) do not pose significant infection risks to humans. Consequently, from a human health perspective, land use practices in agricultural watersheds that create opportunities for wildlife to flourish should not be rejected solely on the basis of their potential to increase relative proportions of wildlife fecal contamination in surface water. The present study suggests that mitigating livestock fecal pollution in surface water in this region would likely reduce human infection risks associated with Cryptosporidium and other zoonotic pathogens.

Participatory probabilistic assessment of the risk to human health associated with cryptosporidiosis from urban dairying in Dagoretti, Nairobi, Kenya

We carried out a participatory risk assessment to estimate the risk (negative consequences and their likelihood) from zoonotic Cryptosporidium originating in dairy farms in urban Dagoretti, Nairobi to dairy farm households and their neighbours. We selected 20 households at high risk for Cryptosporidium from a larger sample of 300 dairy households in Dagoretti based on risk factors present. We then conducted a participatory mapping of the flow of the hazard from its origin (cattle) to human potential victims. This showed three main exposure pathways (food and water borne, occupational and recreational). This was used to develop a fault tree model which we parameterised using information from the study and literature. A stochastic simulation was used to estimate the probability of exposure to zoonotic cryptosporidiosis originating from urban dairying. Around 6 % of environmental samples were positive for Cryptosporidium. Probability of exposure to Cryptosporidium from dairy cattle ranged from 0.0055 for people with clinical acquired immunodeficiency syndrome in non-dairy households to 0.0102 for children under 5 years from dairy households. Most of the estimated health burden was born by children. Although dairy cattle are the source of Cryptosporidium, the model suggests consumption of vegetables is a greater source of risk than consumption of milk. In conclusion, by combining participatory methods with quantitative microbial risk assessment, we were able to rapidly, and with appropriate 'imprecision', investigate health risk to communities from Cryptosporidium and identify the most vulnerable groups and the most risky practices.

Considering the risk of infection by cryptosporidium via consumption of municipally treated drinking water from a surface water source in a Southwestern Ontario community

Through the use of case-control analyses and quantitative microbial risk assessment (QMRA), relative risks of transmission of cryptosporidiosis have been evaluated (recreational water exposure vs. drinking water consumption) for a Canadian community with higher than national rates of cryptosporidiosis. A QMRA was developed to assess the risk of Cryptosporidium infection through the consumption of municipally treated drinking water. Simulations were based on site-specific surface water contamination levels and drinking water treatment log₁₀ reduction capacity for Cryptosporidium. Results suggested that the risk of Cryptosporidium infection via drinking water in the study community, assuming routine operation of the water treatment plant, was negligible (6 infections per 10¹³ persons per day--5th percentile: 2 infections per 10¹⁵ persons per day; 95th percentile: 3 infections per 10¹² persons per day). The risk is essentially nonexistent during optimized, routine treatment operations. The study community achieves between 7 and 9 log₁₀ Cryptosporidium oocyst reduction through routine water treatment processes. Although these results do not preclude the need for constant vigilance by both water treatment and public health professionals in this community, they suggest that the cause of higher rates of cryptosporidiosis are more likely due to recreational water contact, or perhaps direct animal contact. QMRA can be successfully applied at the community level to identify data gaps, rank relative public health risks, and forecast future risk scenarios. It is most useful when performed in a collaborative way with local stakeholders, from beginning to end of the risk analysis paradigm.

Cryptosporidium and Giardia detection in water bodies of Galicia, Spain

The objective of this study was to determine the mean concentration (per litre) of Cryptosporidium oocysts and Giardia cysts in recreational river areas (n = 28), drinking water treatments plants (DWTPs; n = 52) and wastewater treatment plants (WWTPs; n = 50) in Galicia (NW Spain). Water samples from rivers and from the influent (50-100 l) and the treated effluent (100 l) of the water plants were filtered using Filta-Max filters (IDEXX Laboratories, Inc., Westbrook, ME, USA). A total of 232 samples were processed and the (oo)cysts were concentrated, clarified by IMS and then detected by IFAT. The viability was determined by applying fluorogenic vital dye (PI). In the recreational areas, infective forms of Cryptosporidium and Giardia were detected in 16 (57.1%; 1-60 oocysts per litre) and 17 (60.7%; 1-160 cysts per litre) samples, respectively. In the water flowing into the water treatment plants, oocysts were detected in 21 DWTPs (40.4%; 1-13 oocysts per litre) and cysts were observed in 22 DWTPs (42.3%; 1-7 cysts per litre). In the effluents from the treatment plants, Cryptosporidium oocysts and Giardia cysts were identified in 17 DWTPs (32.7%; 1-4 oocysts per litre) and in 19 DWTPs (36.5%; 1-5 cysts per litre), respectively. The highest concentrations of (oo)cysts were found in the WWTPs; specifically, oocysts were detected in 29 (58.0%; 1-80 oocysts per litre) and cysts in 49 (98.0%; 2-14.400 cysts per litre) WWTP effluents. Cryptosporidium and Giardia were detected in 32 (64.0%; 1-120 oocysts per litre) and 48 (96.0%; 2-6.000 cysts per litre) WWTP effluents, respectively. The percentage viability of the (oo)cysts ranged between 90.0% and 95.0%. In all samples analysed. Moreover, it was found that the effluents from coastal WWTPs were discharged directly into the sea, while inland WWTPs were discharged directly into rivers. The concentrations of both enteropathogens detected in effluents from WWTPs therefore represent a significant risk to human and animal health. These results demonstrate the wide distribution of Cryptosporidium and Giardia in the environment, the ineffectiveness of treatments in DWTPs and WWTPs in reducing/inactivating both protozoa and the need to monitor the presence, viability and infectivity of Cryptosporidium and Giardia in water bodies. In conclusion, the findings suggest the need for better monitoring of water quality and identification of sources of contamination.