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常 婧, 党 芸, 王 春, 李 秀. [Effect of Using Hydrogen Peroxide for Periodic Disinfection Combined With Continuous Disinfection to Control Contamination in Dental Unit Waterline]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2024; 55:217-223. [PMID: 38322511 PMCID: PMC10839502 DOI: 10.12182/20240160210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Indexed: 02/08/2024]
Abstract
Objective To observe the effect of using hydrogen peroxide in periodic disinfection combining with continuous disinfection of dental unit waterlines and to provide references for the selection of waterway disinfection measures. Methods A total of 4 dental units in a hospital of stomatology were selected through convenience sampling. The dental unit waterlines received periodic disinfection once every 4 weeks in addition to continuous disinfection (When the dental units were not used for more than 3 days, an additional periodic disinfection would be performed.). Periodic disinfection referred to filling up the waterlines with a disinfectant solution (1.4% hydrogen peroxide) by using the waterline disinfection device that came with the dental unit, immersing for 24 hours, and then emptying out the disinfectant solution. Continuous disinfection referred to using hydrogen peroxide at a concentration of 0.014% as dental treatment water and using it to flush the waterlines for 2 minutes before any dental treatment in the morning and to flush the waterlines for 30 seconds after each dental treatment. The study lasted for 25 weeks, with periodic disinfection being performed for 7 times and continuous disinfection carried out for the rest of the dental treatment time. During the 25 weeks, water samples were collected from air/water syringes and high-speed handpieces. Then, the water samples were incubated and the bacterial concentration and the qualification rates were calculated accordingly. When the bacterial concentration≤100 CFU/ mL, the water samples were considered to be qualified. Waterline tubes of 1 cm were collected before and after the 25 weeks of disinfection with hydrogen peroxide. Biofilms in the waterline tube were observed under scanning electron microscope. Results A total of 352 water samples were collected. Eight water samples were collected before disinfection with hydrogen peroxide, with the median of bacterial concentration being 3140 CFU/mL. On the first day of disinfection with hydrogen peroxide, the median bacterial concentration in dental treatment water was 7.5 CFU/mL. There was a significant difference between the bacterial concentration of the water samples before the disinfection and that after the disinfection (P=0.012). A total of 344 water samples were collected after the disinfection, with the median bacterial concentrations for air/water syringes and high-speed handpieces being 11 CFU/mL and 11CFU/mL and the qualified rates being 83.7% and 82.0%, respectively. There was no significant difference in bacterial concentration or the qualification rates. During week 1 through week 9 of the disinfection, the qualification rates of the dental treatment water always exceeded 80% in 8 weeks, with week 3 being the exception. In the two four-week disinfection periods of week 14 through week 17 and week 18 through week 21, the qualification rate was maintained at above 80% for only the first two weeks and started to decrease from the third week. Biofilm morphology was observed under scanning electron microscope. Before the disinfection, the biofilm was found to be a dense structure and the mixture of a large number of bacteria. After 25 weeks of the disinfection, the biofilm structure appeared to be loose and did not show consistent characteristics of a large number of bacteria retained. Conclusion Periodic disinfection combined with continuous disinfection using hydrogen peroxide can effectively control contamination in dental unit waterlines. But the cycles of periodic disinfection and the concentration of hydrogen peroxide for continuous disinfection should be further discussed according to the actual clinical situation.
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Affiliation(s)
- 婧 常
- 北京大学口腔医学院·口腔医院第五门诊部 国家口腔医学中心 国家口腔疾病临床医学研究中心 口腔生物材料和数字诊疗装备国家工程研究中心 (北京 100081)Fifth Clinical Division, Peking University School and Hospital of Stomatology, National Center for Stomatology, National Clinical Research Center for Oral Diseases, and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, China
| | - 芸 党
- 北京大学口腔医学院·口腔医院第五门诊部 国家口腔医学中心 国家口腔疾病临床医学研究中心 口腔生物材料和数字诊疗装备国家工程研究中心 (北京 100081)Fifth Clinical Division, Peking University School and Hospital of Stomatology, National Center for Stomatology, National Clinical Research Center for Oral Diseases, and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, China
| | - 春丽 王
- 北京大学口腔医学院·口腔医院第五门诊部 国家口腔医学中心 国家口腔疾病临床医学研究中心 口腔生物材料和数字诊疗装备国家工程研究中心 (北京 100081)Fifth Clinical Division, Peking University School and Hospital of Stomatology, National Center for Stomatology, National Clinical Research Center for Oral Diseases, and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, China
| | - 秀娥 李
- 北京大学口腔医学院·口腔医院第五门诊部 国家口腔医学中心 国家口腔疾病临床医学研究中心 口腔生物材料和数字诊疗装备国家工程研究中心 (北京 100081)Fifth Clinical Division, Peking University School and Hospital of Stomatology, National Center for Stomatology, National Clinical Research Center for Oral Diseases, and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, China
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Chen P, Zeng J, Hong F, Li C, Wang H, Yu X. The importance of biofilm contamination control for dental unit waterlines: a multicenter assessment of the microbiota diversity of biofilm in dental unit waterlines. J Oral Microbiol 2023; 16:2299496. [PMID: 38174123 PMCID: PMC10763872 DOI: 10.1080/20002297.2023.2299496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024] Open
Abstract
Background The biofilm formation in Dental Unit Waterlines (DUWLs) could become an important cause of infection during dental care, which could put immunocompromised individuals at risk of cross-infection. The aim of this study was to characterize the microbial communities of biofilms among DUWLs using high-throughput sequencing technology. Methods Twenty-nine biofilm samples were obtained from 24 dental chair units at 5 hospitals and 2 dental clinics. The genomic DNA of the samples was extracted, then 16S rDNA and ITS2 gene were amplified and sequenced. Alpha-diversity and Beta-diversity were calculated with QIIME2 and the Kruskal - Wallis H-test was adopted for statistical analysis. Results Microbial communities with a high diversity of bacteria (377 genera) and fungi (83 genera) were detected in the biofilm samples. The dominant phylum of bacteria was Proteobacteria (93.27%) and that of fungi was Basidiomycota (68.15%). Potential human pathogens were detected including 7 genera of bacteria (Pseudomonas, Stenotrophomonas, Hafnia-Obesumbacterium, Burkholderia-Caballeronia-Paraburkholderia, Ralstonia, Enterobacter, Klebsiella) and 6 genera of fungi (Malassezia, Candida, Alternaria, Cryptococcus, Rhodotorula, Rhinocladiella). Conclusions This multicenter assessment revealed the infectious risk during dental care. It emphasized the importance of biofilm control due to biofilm accumulation and multiple kinds of opportunistic pathogens in DUWLs.
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Affiliation(s)
- Piaopiao Chen
- Key Laboratory of Oral Biomedical Research of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jiang Zeng
- Key Laboratory of Oral Biomedical Research of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Feiruo Hong
- Stomatology Hospital, School of Stomatology, Zhejiang, University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Hangzhou, ZhejiangChina
| | - Cong Li
- Stomatology Hospital, School of Stomatology, Zhejiang, University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Hangzhou, ZhejiangChina
| | - Huimin Wang
- School & Hospital of Stomatology, Wenzhou Medical University, Wenzhou, China
| | - Xuefen Yu
- Stomatology Hospital, School of Stomatology, Zhejiang, University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Hangzhou, ZhejiangChina
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Lao CK, Wu TS, Lin KY, Lee MH. Disseminated Mycobacterium peregrinum and Mycobacterium avium infection in a patient with AIDS: A case report and review of literature. J Clin Tuberc Other Mycobact Dis 2022; 27:100314. [PMID: 35492430 PMCID: PMC9038537 DOI: 10.1016/j.jctube.2022.100314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Disseminated nontuberculous mycobacterial infections are frequently recognized in patients living with human immunodeficiency virus/acquired immunodeficiency syndrome (AIDS) and Mycobacterium avium-intracellulare complex (MAIC) is the most common species. Mycobacterium peregrinum is a rapidly growing mycobacterium that accounts for 1–2% of community-acquired and healthcare-associated infections. It mainly causes skin and soft tissue infection. Disseminated infection by M. peregrinum has never been reported in patients with AIDS. We describe a case of disseminated co-infection of M. peregrinum and M. avium in a 33-year-old male with newly diagnosed AIDS, and review the literature regarding M. peregrinum infection. The patient’s bone marrow culture grew M. peregrinum and his blood culture grew M. avium. The diagnosis of disseminated co-infection of M. peregrinum and M. avium was confirmed. Disseminated infection due to M. peregrinum is rare and diagnosis can be challenging. Due to limited case numbers, there is no treatment guideline for M. peregrinum nowadays. Further study is warranted for better understanding M. peregrinum related infections.
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Morita Y, Kondo Y, Takeuchi E. Pulmonary mycobacteriosis caused by Mycobacterium peregrinum: A case report. Medicine (Baltimore) 2022; 101:e28809. [PMID: 35147117 PMCID: PMC8830817 DOI: 10.1097/md.0000000000028809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 01/25/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Mycobacterium peregrinum is a member of the group of rapidly growing nontuberculous mycobacteria. It mainly causes surgical site and catheter-related infections, while pulmonary infection is rare. We herein present a case of pulmonary infection caused by M peregrinum. PATIENT CONCERNS A 62-year-old woman visited our hospital with dyspnea and was admitted for the treatment of pneumonia in July 2018. DIAGNOSIS Chest computed tomography showed patchy opacities and consolidation in the bilateral lungs and a cavity in the right upper lobe, which persisted after the treatment of bacterial pneumonia 5 years ago. She was administered ceftriaxone and azithromycin. Consolidation in the bilateral lungs improved, whereas the cavity in the right upper lobe remained and the consolidation surrounding it gradually spread. On admission, the sputum acid-fast bacillus culture was positive, and M peregrinum was identified twice by mass spectrometry. The cavity and consolidation surrounding it were diagnosed as pulmonary mycobacteriosis caused by M peregrinum. INTERVENTIONS Although we recommended treatment for mycobacteriosis, the patient refused it. OUTCOMES The patient is regularly followed up; however, the cavity wall is thickening and shadows have become mildly enhanced over the course of 3 years. LESSONS We herein present a rare case of pulmonary mycobacteriosis caused by M peregrinum and discuss the literature. Since limited information is currently available on pulmonary mycobacteriosis caused by M peregrinum, the accumulation of further case reports and the clarification of its clinical features are needed.
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Affiliation(s)
- Yutaka Morita
- Division of Pulmonary Medicine, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi city, Kochi, Japan
- Department of Internal Medicine, Japanese Red Cross Kochi Hospital, 1-4-63-11 Hadaminamimachi, Kochi city, Kochi, Japan
| | - Yoshihiro Kondo
- Division of Pulmonary Medicine, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi city, Kochi, Japan
| | - Eiji Takeuchi
- Department of Clinical Investigation, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi city, Kochi, Japan
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Fan C, Gu H, Liu L, Zhu H, Yan J, Huo Y. Distinct Microbial Community of Accumulated Biofilm in Dental Unit Waterlines of Different Specialties. Front Cell Infect Microbiol 2021; 11:670211. [PMID: 34222041 PMCID: PMC8248794 DOI: 10.3389/fcimb.2021.670211] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/31/2021] [Indexed: 12/26/2022] Open
Abstract
The contamination of dental unit waterlines (DUWLs) is a serious problem and directly affects the dental care. This study aims to explore the microbial community of biofilm in DUWL from different specialties and investigate the associated factors. A total of 36 biofilm samples from 18 DUWL of six specialties (i.e., prosthodontics, orthodontics, pediatrics, endodontics, oral surgery, and periodontics) at two time points (i.e., before and after daily dental practice) were collected with a novel method. Genomic DNA of samples was extracted, and then 16S ribosomal DNA (rDNA) (V3–V4 regions) and ITS2 gene were amplified and sequenced. Kruskal–Wallis and Wilcoxon rank test were adopted for statistical analysis. Microbial community with high diversity of bacteria (631 genera), fungi (193 genera), and viridiplantae was detected in the biofilm samples. Proteobacteria was the dominant bacteria (representing over 65.74–95.98% of the total sequences), and the dominant fungi was Ascomycota (93.9–99.3%). Microorganisms belonging to multiple genera involved in human diseases were detected including 25 genera of bacteria and eight genera of fungi, with relative abundance of six genera over 1% (i.e., Acinetobacter, Pseudomonas, Enterobacter, Aspergillus, Candida, and Penicillium). The biofilm microbiome may be influenced by the characteristics of dental specialty and routine work to some extent. The age of dental chair unit and overall number of patients had the strongest impact on the overall bacteria composition, and the effect of daily dental practices (associated with number of patients and dental specialty) on the fungi composition was the greatest. For the first time, biofilm in DUWL related to dental specialty was comprehensively evaluated, with more abundance of bacterial and fungal communities than in water samples. Biofilm accumulation with daily work and multiple kinds of opportunistic pathogen emphasized the infectious risk with dental care and the importance of biofilm control.
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Affiliation(s)
- Cancan Fan
- Zhujiang New Town Clinic, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Haijing Gu
- Zhujiang New Town Clinic, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Limin Liu
- Zhujiang New Town Clinic, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Haiwei Zhu
- Zhujiang New Town Clinic, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Juan Yan
- Zhujiang New Town Clinic, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Yongbiao Huo
- Zhujiang New Town Clinic, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
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Singh J, O'Donnell K, Nieves DJ, Adler-Shohet FC, Arrieta AC, Ashouri N, Ahuja G, Cheung M, Holmes WN, Huoh K, Tran L, Tran MT, Pham N, Zahn M. Invasive Mycobacterium abscessus Outbreak at a Pediatric Dental Clinic. Open Forum Infect Dis 2021; 8:ofab165. [PMID: 34113683 PMCID: PMC8186244 DOI: 10.1093/ofid/ofab165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/26/2021] [Indexed: 11/25/2022] Open
Abstract
Background Mycobacterium species, specifically M. abscessus and M. chelonae (MABs), are known to contaminate water systems and are uncommon causes of health care–associated infection, but morbidity can be significant and treatment complex. Methods Odontogenic MAB infections occurred in patients following pulpotomy procedures at dental clinic A from 1 January to 6 September 2016. We identified confirmed and probable cases using culture data, imaging, pathology results, and surgical findings. Epidemiologic and clinical data including demographics, symptoms, laboratory findings, treatment regimens, and outcomes were extracted. Results Of 1082 at-risk patients, 71 case patients (22 confirmed; 49 probable) were identified. Median age was 6 years. Median symptom onset was 85 days postpulpotomy. Pain and/or swelling on admission occurred in 79%. On imaging, 49 of 70 had abnormalities of the mandible or maxilla, 13 of 70 had lymphadenopathy, and 19 of 68 had pulmonary nodules. Seventy were hospitalized (average of 8.5 days). Intravenous antibiotics were administered to 32 cases for a median length of 137 days. Clofazimine was administered to 29 patients as part of their multidrug regimen. Antibiotic treatment was associated with many adverse effects. Treated children showed evidence of jaw healing with resolved/improving pulmonary nodules at 1-year follow-up. Conclusions This is the largest outbreak of invasive MAB infections associated with a pediatric dental practice. While infections were indolent, patients suffered medical and surgical consequences of treatment, including permanent tooth loss. Identification of this outbreak led to a change in water standards for pediatric dental procedures in California. Enhanced national dental water quality standards are needed to prevent future outbreaks.
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Affiliation(s)
- Jasjit Singh
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Kathleen O'Donnell
- Disease Control and Epidemiology, Orange County Health Care Agency, Santa Ana, California, USA
| | - Delma J Nieves
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Felice C Adler-Shohet
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Antonio C Arrieta
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Negar Ashouri
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Gurpreet Ahuja
- Department of Pediatric Otolaryngology, Children's Hospital of Orange County, Orange, California, USA.,University of California, Irvine School of Medicine, Irvine, California, USA
| | - Michele Cheung
- Disease Control and Epidemiology, Orange County Health Care Agency, Santa Ana, California, USA
| | - W Nathan Holmes
- Department of Pediatric Radiology, Children's Hospital of Orange County, Orange, California, USA
| | - Kevin Huoh
- Department of Pediatric Otolaryngology, Children's Hospital of Orange County, Orange, California, USA.,University of California, Irvine School of Medicine, Irvine, California, USA
| | - Lisa Tran
- Department of Surgery, Children's Hospital of Orange County, Orange, California, USA
| | - M Tuan Tran
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Nguyen Pham
- Department of Pediatric Otolaryngology, Children's Hospital of Orange County, Orange, California, USA.,University of California, Irvine School of Medicine, Irvine, California, USA
| | - Matthew Zahn
- Disease Control and Epidemiology, Orange County Health Care Agency, Santa Ana, California, USA
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Castellano Realpe OJ, Gutiérrez JC, Sierra DA, Pazmiño Martínez LA, Prado Palacios YY, Echeverría G, de Waard JH. Dental Unit Waterlines in Quito and Caracas Contaminated with Nontuberculous Mycobacteria: A Potential Health Risk in Dental Practice. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2348. [PMID: 32244267 PMCID: PMC7177417 DOI: 10.3390/ijerph17072348] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/16/2020] [Accepted: 02/20/2020] [Indexed: 11/17/2022]
Abstract
Three cases of severe odontogenic infections due to nontuberculous mycobacteria (NTM) in Venezuela that were directly associated with dental procedures and the finding of dental unit waterlines (DUWLs) in dental offices that were colonized with mycobacteria species was the reason for assessing the water quality of DUWLs in dental offices in two capital cities in South America, namely, Quito and Caracas. The main water supplies and the water from 143 DUWLs in both cities were sampled and especially checked for contamination with NTM. To measure the overall bacteriological quality of the water also the presence of heterotrophic bacteria, coliform bacteria, and Pseudomonas was determined. Results showed that respectively 3% and 56% of the DUWLs in Quito and Caracas yielded NTM species (up to 1000 colony-forming units (CFU)/mL). Furthermore, high and unacceptable total viable counts of heterotrophic bacteria and/or coliform bacteria and Pseudomonas were detected in 73% of the samples. We conclude that, in both cities, the water in the majority of DUWLs was contaminated with NTM and other potential pathogens, presenting a risk to human health. The detection of NTM in DUWL water with acceptable heterotrophic bacteria counts shows the need to include NTM in water quality testing. Mycobacteria are more resistant to disinfection procedures than other types of vegetative bacteria, and most testing protocols for DUWLs do not assess mycobacteria and thus do not guarantee risk-free water.
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Affiliation(s)
| | - Johanna C. Gutiérrez
- Facultad de Medicina. Escuela de Bioanálisis, Universidad Central de Venezuela, 1053 Caracas, Venezuela
- Instituto de Biomedicina “Dr. Jacinto Convit”, Universidad Central de Venezuela, 1010 Caracas, Venezuela
| | - Deisy A. Sierra
- Facultad de Medicina. Escuela de Bioanálisis, Universidad Central de Venezuela, 1053 Caracas, Venezuela
- Instituto de Biomedicina “Dr. Jacinto Convit”, Universidad Central de Venezuela, 1010 Caracas, Venezuela
| | | | - Yrneh Y. Prado Palacios
- Instituto de Biomedicina “Dr. Jacinto Convit”, Universidad Central de Venezuela, 1010 Caracas, Venezuela
| | - Gustavo Echeverría
- Instituto de Investigación en Salud Pública y Zoonosis CIZ, Universidad Central del Ecuador, 170521 Quito, Ecuador
| | - Jacobus H. de Waard
- Instituto de Biomedicina “Dr. Jacinto Convit”, Universidad Central de Venezuela, 1010 Caracas, Venezuela
- One Health Research Group, Facultad de Ciencias de la Salud, Universidad De Las Américas, 170504 Quito, Ecuador
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