Epidemiology and Ecology of Opportunistic Premise Plumbing Pathogens: Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa

Tap water microbiome shifts in secondary water supply for high-rise buildings

In high-rise buildings, secondary water supply systems (SWSSs) are pivotal yet provide a conducive milieu for microbial proliferation due to intermittent flow, low disinfectant residual, and high specific pipe-surface area, raising concerns about tap water quality deterioration. Despite their ubiquity, a comprehensive understanding of bacterial community dynamics within SWSSs remains elusive. Here we show how intrinsic SWSS variables critically shape the tap water microbiome at distal ends. In an office setting, distinct from residential complexes, the diversity in piping materials instigates a noticeable bacterial community shift, exemplified by a transition from α-Proteobacteria to γ-Proteobacteria dominance, alongside an upsurge in bacterial diversity and microbial propagation potential. Extended water retention within SWSSs invariably escalates microbial regrowth propensities and modulates bacterial consortia, yet secondary disinfection emerges as a robust strategy for preserving water quality integrity. Additionally, the regularity of water usage modulates proximal flow dynamics, thereby influencing tap water's microbial landscape. Insights garnered from this investigation lay the groundwork for devising effective interventions aimed at safeguarding microbiological standards at the consumer's endpoint.

It's getting hot in here: Effects of heat on temperature, disinfection, and opportunistic pathogens in drinking water distribution systems

As global temperatures rise with climate change, the negative effects of heat on drinking water distribution systems (DWDS) are of increasing concern. High DWDS temperatures are associated with degradation of water quality through physical, chemical and microbial mechanisms. Perhaps the most pressing concern is proliferation of thermotolerant opportunistic pathogens (OPs) like Legionella pneumophila and Naegleria Fowleri. Many OPs can be controlled in DWDS by residual disinfectants such as chlorine or chloramine, but maintaining protective residuals can be challenging at high temperatures. This critical review evaluates the literature on DWDS temperature, residual disinfectant decay, and OP survival and growth with respect to high temperatures. The findings are synthesized to determine the state of knowledge and future research priorities regarding OP proliferation and control at high DWDS temperatures. Temperatures above 40 °C were reported from multiple DWDS, with a maximum of 52 °C. Substantial diurnal temperature swings from ∼30-50 °C occurred in one DWDS. Many OPs can survive or even replicate at these temperatures. However, most studies focused on just a few OP species, and substantial knowledge gaps remain regarding persistence, infectivity, and shifts in microbial community structure at high temperatures relative to lower water temperatures. Chlorine decay rates substantially increase with temperature in some waters but not in others, for reasons that are not well understood. Decay rates within real DWDS are difficult to accurately characterize, presenting practical limitations for application of temperature-dependent decay models at full scale. Chloramine decay is slower than chlorine except in the presence of nitrifiers, which are especially known to grow in DWDS in warmer seasons and climates, though the high temperature range for nitrification is unknown. Lack of knowledge about DWDS nitrifier communities may hinder development of solutions. Fundamental knowledge gaps remain which prevent understanding even the occurrence of high temperatures in DWDS, much less the overall effect on exposure risk. Potential solutions to minimize DWDS temperatures or mitigate the impacts of heat were identified, many which could be aided by proven models for predicting DWDS temperature. Industry leadership and collaboration is needed to generate practical knowledge for protecting DWDS water quality as temperatures rise.

Ecology of Legionella pneumophila biofilms: The link between transcriptional activity and the biphasic cycle

There has been considerable discussion regarding the environmental life cycle of Legionella pneumophila and its virulence potential in natural and man-made water systems. On the other hand, the bacterium's morphogenetic mechanisms within host cells (amoeba and macrophages) have been well documented and are linked to its ability to transition from a non-virulent, replicative state to an infectious, transmissive state. Although the morphogenetic mechanisms associated with the formation and detachment of the L. pneumophila biofilm have also been described, the capacity of the bacteria to multiply extracellularly is not generally accepted. However, several studies have shown genetic pathways within the biofilm that resemble intracellular mechanisms. Understanding the functionality of L. pneumophila cells within a biofilm is fundamental for assessing the ecology and evaluating how the biofilm architecture influences L. pneumophila survival and persistence in water systems. This manuscript provides an overview of the biphasic cycle of L. pneumophila and its implications in associated intracellular mechanisms in amoeba. It also examines the molecular pathways and gene regulation involved in L. pneumophila biofilm formation and dissemination. A holistic analysis of the transcriptional activities in L. pneumophila biofilms is provided, combining the information of intracellular mechanisms in a comprehensive outline. Furthermore, this review discusses the techniques that can be used to study the morphogenetic states of the bacteria within biofilms, at the single cell and population levels.

A Delicate Balance: Water Disinfection and By-Product Immunotoxicity

Mouse macrophages and human blood cells exposed to very high levels of three trihalophenols showed changes in RNA methylation, pointing to one mechanism by which disinfection by-products may harm health, even as disinfection protects it in other ways.

Surveillance of Waterborne Disease Outbreaks Associated with Drinking Water - United States, 2015-2020

Problem/Condition

Public health agencies in U.S. states, territories, and freely associated states investigate and voluntarily report waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS). This report summarizes NORS drinking water outbreak epidemiologic, laboratory, and environmental data, including data for both public and private drinking water systems. The report presents outbreak-contributing factors (i.e., practices and factors that lead to outbreaks) and, for the first time, categorizes outbreaks as biofilm pathogen or enteric illness associated.

Period Covered

2015-2020.

Description of System

CDC launched NORS in 2009 as a web-based platform into which public health departments voluntarily enter outbreak information. Through NORS, CDC collects reports of enteric disease outbreaks caused by bacterial, viral, parasitic, chemical, toxin, and unknown agents as well as foodborne and waterborne outbreaks of nonenteric disease. Data provided by NORS users, when known, for drinking water outbreaks include 1) the number of cases, hospitalizations, and deaths; 2) the etiologic agent (confirmed or suspected); 3) the implicated type of water system (e.g., community or individual or private); 4) the setting of exposure (e.g., hospital or health care facility; hotel, motel, lodge, or inn; or private residence); and 5) relevant epidemiologic and environmental data needed to describe the outbreak and characterize contributing factors.

Results

During 2015-2020, public health officials from 28 states voluntarily reported 214 outbreaks associated with drinking water and 454 contributing factor types. The reported etiologies included 187 (87%) biofilm associated, 24 (11%) enteric illness associated, two (1%) unknown, and one (<1%) chemical or toxin. A total of 172 (80%) outbreaks were linked to water from public water systems, 22 (10%) to unknown water systems, 17 (8%) to individual or private systems, and two (0.9%) to other systems; one (0.5%) system type was not reported. Drinking water-associated outbreaks resulted in at least 2,140 cases of illness, 563 hospitalizations (26% of cases), and 88 deaths (4% of cases). Individual or private water systems were implicated in 944 (43%) cases, 52 (9%) hospitalizations, and 14 (16%) deaths.Enteric illness-associated pathogens were implicated in 1,299 (61%) of all illnesses, and 10 (2%) hospitalizations. No deaths were reported. Among these illnesses, three pathogens (norovirus, Shigella, and Campylobacter) or multiple etiologies including these pathogens resulted in 1,225 (94%) cases. The drinking water source was identified most often (n = 34; 7%) as the contributing factor in enteric disease outbreaks. When water source (e.g., groundwater) was known (n = 14), wells were identified in 13 (93%) of enteric disease outbreaks.Most biofilm-related outbreak reports implicated Legionella (n = 184; 98%); two nontuberculous mycobacteria (NTM) (1%) and one Pseudomonas (0.5%) outbreaks comprised the remaining. Legionella-associated outbreaks generally increased over the study period (14 in 2015, 31 in 2016, 30 in 2017, 34 in 2018, 33 in 2019, and 18 in 2020). The Legionella-associated outbreaks resulted in 786 (37%) of all illnesses, 544 (97%) hospitalizations, and 86 (98%) of all deaths. Legionella also was the outbreak etiology in 160 (92%) public water system outbreaks. Outbreak reports cited the premise or point of use location most frequently as the contributing factor for Legionella and other biofilm-associated pathogen outbreaks (n = 287; 63%). Legionella was reported to NORS in 2015 and 2019 as the cause of three outbreaks in private residences (2).

Interpretation

The observed range of biofilm and enteric drinking water pathogen contributing factors illustrate the complexity of drinking water-related disease prevention and the need for water source-to-tap prevention strategies. Legionella-associated outbreaks have increased in number over time and were the leading cause of reported drinking water outbreaks, including hospitalizations and deaths. Enteric illness outbreaks primarily linked to wells represented approximately half the cases during this reporting period. This report enhances CDC efforts to estimate the U.S. illness and health care cost impacts of waterborne disease, which revealed that biofilm-related pathogens, NTM, and Legionella have emerged as the predominant causes of hospitalizations and deaths from waterborne- and drinking water-associated disease.

Public Health Action

Public health departments, regulators, and drinking water partners can use these findings to identify emerging waterborne disease threats, guide outbreak response and prevention programs, and support drinking water regulatory efforts.

Bacterial communities of planktonic bacteria and mature biofilm in service lines and premise plumbing of a Megacity: Composition, Diversity, and influencing factors

Although simulated studies have provided valuable knowledge regarding the communities of planktonic bacteria and biofilms, the lack of systematic field studies have hampered the understanding of microbiology in real-world service lines and premise plumbing. In this study, the bacterial communities of water and biofilm were explored, with a special focus on the lifetime development of biofilm communities and their key influencing factors. The 16S rRNA gene sequencing results showed that both the planktonic bacteria and biofilm were dominated by Proteobacteria. Among the 15,084 observed amplicon sequence variants (ASVs), the 33 core ASVs covered 72.8 %, while the 12 shared core ASVs accounted for 62.2 % of the total sequences. Remarkably, it was found that the species richness and diversity of biofilm communities correlated with pipe age. The relative abundance of ASV2 (f_Sphingomonadaceae) was lower for pipe ages 40-50 years (7.9 %) than for pipe ages 10-20 years (59.3 %), while the relative abundance of ASV10 (f_Hyphomonadaceae) was higher for pipe ages 40-50 years (19.5 %) than its presence at pipe ages 20-30 years (1.9 %). The community of the premise plumbing biofilm had significantly higher species richness and diversity than that of the service line, while the steel-plastics composite pipe interior lined with polyethylene (S-PE) harbored significantly more diverse biofilm than the galvanized steel pipes (S-Zn). Interestingly, S-PE was enriched with ASV27 (g_Mycobacterium), while S-Zn pipes were enriched with ASV13 (g_Pseudomonas). Moreover, the network analysis showed that five rare ASVs, not core ASVs, were keystone members in biofilm communities, indicating the importance of rare members in the function and stability of biofilm communities. This manuscript provides novel insights into real-world service lines and premise plumbing microbiology, regarding lifetime dynamics (pipe age 10-50 years), and the influences of pipe types (premise plumbing vs. service line) and pipe materials (S-Zn vs. S-PE).

On-site filtration of large sample volumes improves the detection of opportunistic pathogens in drinking water distribution systems

In this study, we compared conventional vacuum filtration of small volumes through disc membranes (effective sample volumes for potable water: 0.3-1.0 L) with filtration of high volumes using ultrafiltration (UF) modules (effective sample volumes for potable water: 10.6-84.5 L) for collecting bacterial biomass from raw, finished, and tap water at seven drinking water systems. Total bacteria, Legionella spp., Legionella pneumophila, Mycobacterium spp., and Mycobacterium avium complex in these samples were enumerated using both conventional quantitative PCR (qPCR) and viability qPCR (using propidium monoazide). In addition, PCR-amplified gene fragments were sequenced for microbial community analysis. The frequency of detection (FOD) of Legionella spp. in finished and tap water samples was much greater using UF modules (83% and 77%, respectively) than disc filters (24% and 33%, respectively). The FODs for Mycobacterium spp. in raw, finished, and tap water samples were also consistently greater using UF modules than disc filters. Furthermore, the number of observed operational taxonomic units and diversity index values for finished and tap water samples were often substantially greater when using UF modules as compared to disc filters. Conventional and viability qPCR yielded similar results, suggesting that membrane-compromised cells represented a minor fraction of total bacterial biomass. In conclusion, our research demonstrates that large-volume filtration using UF modules improved the detection of opportunistic pathogens at the low concentrations typically found in public drinking water systems and that the majority of bacteria in these systems appear to be viable in spite of disinfection with free chlorine and/or chloramine.IMPORTANCEOpportunistic pathogens, such as Legionella pneumophila, are a growing public health concern. In this study, we compared sample collection and enumeration methods on raw, finished, and tap water at seven water systems throughout the State of Minnesota, USA. The results showed that on-site filtration of large water volumes (i.e., 500-1,000 L) using ultrafiltration membrane modules improved the frequency of detection of relatively rare organisms, including opportunistic pathogens, compared to the common approach of filtering about 1 L using disc membranes. Furthermore, results from viability quantitative PCR (qPCR) with propidium monoazide were similar to conventional qPCR, suggesting that membrane-compromised cells represent an insignificant fraction of microorganisms. Results from these ultrafiltration membrane modules should lead to a better understanding of the microbial ecology of drinking water distribution systems and their potential to inoculate premise plumbing systems with opportunistic pathogens where conditions are more favorable for their growth.

Microbial ecology of drinking water from source to tap

As drinking water travels from its source, through various treatment processes, hundreds to thousands of kilometres of distribution network pipes, to the taps in private homes and public buildings, it is exposed to numerous environmental changes, as well as other microbes living in both water and on surfaces. This review aims to identify the key locations and factors that are associated with changes in the drinking water microbiome throughout conventional urban drinking water systems from the source to the tap water. Over the past 15 years, improvements in cultivation-independent methods have enabled studies that allow us to answer such questions. As a result, we are beginning to move towards predicting the impacts of disturbances and interventions resulting ultimately in management of drinking water systems and microbial communities rather than mere observation. Many challenges still exist to achieve effective management, particularly within the premise plumbing environment, which exhibits diverse and inconsistent conditions that may lead to alterations in the microbiota, potentially presenting public health risks. Finally, we recommend the establishment of global collaborative projects on the drinking water microbiome that will enhance our current knowledge and lead to tools for operators and researchers alike to improve global access to high-quality drinking water.

Estimating the burden of illness caused by domestic waterborne Legionnaires' disease in Canada: 2015-2019

Legionellosis is a disease caused by the bacterium Legionella that most commonly presents as Legionnaires' disease (LD), a severe form of pneumonia. From 2015 to 2019, an average of 438 LD cases per year were reported in Canada. However, it is believed that the actual number of cases is much higher, since LD may be underdiagnosed and underreported. The purpose of this study was to develop an estimate of the true incidence of illnesses, hospitalizations, and deaths associated with LD in Canada. Values were derived using a stochastic model, based on Canadian surveillance data from 2015 to 2019, which were scaled up to account for underdiagnosis and underreporting. Overall, there were an estimated 1,113 (90% CrI: 737-1,730) illnesses, 1,008 (90% CrI: 271-2,244) hospitalizations, and 34 (90% CrI: 4-86) deaths due to domestically acquired waterborne LD annually in Canada from 2015 to 2019. It was further estimated that only 36% of illnesses and 39% of hospitalizations and deaths were captured in surveillance, and that 22% of illnesses were caused by Legionella serogroups and species other than Legionella pneumophila serogroup 1 (non-Lp1). This study highlights the true burden and areas for improvement in Canada's surveillance and detection of LD.

A synergistic anti-bacterial and anti-adhesion activity of tea tree (Melaleuca alternifolia) and lemon eucalyptus tree (Eucalyptus citriodora Hook) essential oils on Legionella pneumophila

Legionella pneumophila is a Gram-negative bacterial pathogen that colonizes natural and artificial water systems and has the ability to form a biofilm. The biofilm protects L. pneumophila from various environmental factors and makes it more resistant to chlorine-based disinfectants. This study investigated the anti-bacterial properties of tea tree (Melaleuca alternifolia (Maiden and Betche) Cheel) oil and lemon eucalyptus tree (Eucalyptus citriodora Hook) essential oils (EOs) and their synergistic, additive inhibitory and anti-adhesive effects against L. pneumophila biofilm formation on polystyrene. The minimum effective concentration (MEC) for tea tree is 12.8 mg ml-1 and for lemon eucalyptus tree EO 6.4 mg ml-1. In the checkerboard assay, different combinations of these two EO show synergistic and additive anti-microbial activity. The minimum anti-adhesive concentration (MAC) for tea tree is 12.8 mg ml-1 and for lemon eucalyptus tree EO 6.4 mg ml-1. A combination of 3.2 mg ml-1 tea tree EO and 0.8 mg ml-1 lemon eucalyptus tree EO showed the strongest anti-adhesive effect against L. pneumophila on polystyrene. The tested oils and their combination showed intriguing potential to inhibit L. pneumophila biofilm formation.

High-Throughput Short Sequence Typing Schemes for Pseudomonas aeruginosa and Stenotrophomonas maltophilia Pure Culture and Environmental DNA

Molecular typing techniques are utilized to determine genetic similarities between bacterial isolates. However, the use of environmental DNA profiling to assess epidemiologic links between patients and their environment has not been fully explored. This work reports the development and validation of two high-throughput short sequence typing (HiSST) schemes targeting the opportunistic pathogens Pseudomonas aeruginosa and Stenotrophomonas maltophilia, along with a modified SM2I selective medium for the specific isolation of S. maltophilia. These HiSST schemes are based on four discriminative loci for each species and demonstrate high discriminating power, comparable to pairwise whole-genome comparisons. Each scheme includes species-specific PCR primers for precise differentiation from closely related taxa, without the need for upstream culture-dependent methods. For example, the primers targeting the bvgS locus make it possible to distinguish P. aeruginosa from the very closely related Pseudomonas paraeruginosa sp. nov. The selected loci included in the schemes are adapted to massive parallel amplicon sequencing technology. An R-based script implemented in the DADA2 pipeline was assembled to facilitate HiSST analyses for efficient and accurate genotyping of P. aeruginosa and S. maltophilia. We demonstrate the performance of both schemes through in silico validations, assessments against reference culture collections, and a case study involving environmental samples.

Multi-criterion analysis of the effect of physico-chemical microbiological agents on Legionella detection in hotel water distribution systems in Crete

Introduction

Water distribution systems in hotels have been related to outbreaks caused by Legionella spp. Certain measures, including disinfection by chlorination, maintaining increased temperatures are usually undertaken to prevent Legionella outbreaks. However, these preventive strategies are not always effective, since there are several factors (e.g., synergistic interactions with other microbes, physico-chemical factors, biofilm formation, availability of nutrients) that promote survival and proliferation of the pathogen in water pipes., Accordingly, there is a need of a holistic approach in development of preventive models for Legionella outbreaks associated with water distribution systems.

Methods

Water samples were collected from hotel water systems and were tested for the presence of Legionella, E. coli, total coliforms, total mesophilic count and Pseudomonas. In each sample, temperature and chlorine were also tested. Other epidemiological factors were additionally recorded including number of rooms, stars, proximity of sampling point to the boiler, etc. Data were processed by generalized linear analysis, and modeling based on logistic regression analysis to identify independent predictive factors associated with the presence of Legionella in hotel water systems.

Results

According to the generalized linear model, temperature affected (p<0.05) the presence of Legionella regardless of the species or the water supply (hot or cold). Additionally, opportunistic (P. aeruginosa) or non-opportunistic (E. coli, coliforms) pathogens were significantly associated (p<0.05) with the presence of all Legionella species. Temperature also exhibited a positive effect to all pathogens tested except for Pseudomonas according to the linear model. Multivariate analysis showed that Pseudomonas, total coliforms, HPC and temperature had a statistically significant effect on the presence of Legionella. Based on a binomial model, cold water had a positive effect on Legionella. Type of sampling and proximity of the sample to the boiler seemed to pose different effect on Legionella depending on the cfu/L. The number of hotel stars and rooms did not appear to have any effect in all tested models.

Discussion

Collectively, these results indicate the need for development of individualized water safety plans tailored by the presence of other microbiological agents, and unique physico-chemical factors, which could facilitate the survival of Legionella.in hotel water systems.

Extended water stagnation in buildings during the COVID-19 pandemic increases the risks posed by opportunistic pathogens

The regrowth and subsequent exposure of opportunistic pathogens (OPs) whilst reopening buildings that have been locked down due to the stay-at-home restrictions to limit the spread of COVID-19, is a public health concern. To better understand such microbiological risks due to lowered occupancy and water demand in buildings, first and post-flush water samples (n = 48) were sampled from 24 drinking water outlets from eight university buildings in two campuses (urban and rural), with various end-user occupancies. Both campuses were served with chlorinated water originating from a single drinking water distribution system in South-East Queensland, situated 14 km apart, where the rural campus had lower chlorine residuals. Culture-dependent and culture-independent methods (such as flow cytometry, qPCR and 16S rRNA gene amplicon sequencing) were used concurrently to comprehensively characterise the OPs of interest (Legionella spp., Pseudomonas aeruginosa, and nontuberculous mycobacteria (NTM)) and the premise plumbing microbiome. Results showed that buildings with extended levels of stagnation had higher and diverse levels of microbial growth, as observed in taxonomic structure and composition of the microbial communities. NTM were ubiquitous in all the outlets sampled, regardless of campus or end-user occupancy of the buildings. qPCR and culture demonstrated prevalent and higher concentrations of NTM in buildings (averaging 3.25 log10[estimated genomic copies/mL]) with extended stagnation in the urban campus. Furthermore, flushing the outlets for 30 minutes restored residual and total chlorine, and subsequently decreased the levels of Legionella by a reduction of 1 log. However, this approach was insufficient to restore total and residual chlorine levels for the outlets in the rural campus, where both Legionella and NTM levels detected by qPCR remained unchanged, regardless of building occupancy. Our findings highlight that regular monitoring of operational parameters such as residual chlorine levels, and the implementation of water risk management plans are important for non-healthcare public buildings, as the levels of OPs in these environments are typically not assessed.

Legionella relative abundance in shower hose biofilms is associated with specific microbiome members

Legionella are natural inhabitants of building plumbing biofilms, where interactions with other microorganisms influence their survival, proliferation, and death. Here, we investigated the associations of Legionella with bacterial and eukaryotic microbiomes in biofilm samples extracted from 85 shower hoses of a multiunit residential building. Legionella spp. relative abundance in the biofilms ranged between 0-7.8%, of which only 0-0.46% was L. pneumophila. Our data suggest that some microbiome members were associated with high (e.g. Chthonomonas, Vrihiamoeba) or low (e.g. Aquabacterium, Vannella) Legionella relative abundance. The correlations of the different Legionella variants (30 Zero-Radius OTUs detected) showed distinct patterns, suggesting separate ecological niches occupied by different Legionella species. This study provides insights into the ecology of Legionella with respect to: (i) the colonization of a high number of real shower hoses biofilm samples; (ii) the ecological meaning of associations between Legionella and co-occurring bacterial/eukaryotic organisms; (iii) critical points and future directions of microbial-interaction-based-ecological-investigations.

Pilot-scale assessment reveals effects of anode type and orthophosphate in governing antimicrobial capacity of copper for Legionella pneumophila control

Copper (Cu) is sometimes applied as an antimicrobial for controlling Legionella in hot water plumbing systems, but its efficacy is inconsistent. Here we examined the effects of Cu (0 - 2 mg/L), orthophosphate corrosion inhibitor (0 or 3 mg/L as phosphate), and water heater anodes (aluminum, magnesium, and powered anodes) on both bulk water and biofilm-associated L. pneumophila in pilot-scale water heater systems. Soluble, but not total, Cu was a good predictor of antimicrobial capacity of Cu. Even after months of exposure to very high Cu levels (>1.2 mg/L) and low pH (<7), which increases solubility and enhances bioavailability of Cu, culturable L. pneumophila was only reduced by ∼1-log. Cu antimicrobial capacity was shown to be limited by various factors, including binding of Cu ions by aluminum hydroxide precipitates released from corrosion of aluminum anodes, higher pH due to magnesium anode corrosion, and high Cu tolerance of the outbreak-associated L. pneumophila strain that was inoculated into the systems. L. pneumophila numbers were also higher in several instances when Cu was dosed together with orthophosphate (e.g., with an Al anode), revealing at least one scenario where high levels of total Cu appeared to stimulate Legionella. The controlled, pilot-scale nature of this study provides new understanding of the limitations of Cu as an antimicrobial in real-world plumbing systems.

Shift of human pathogen community composition and their potential human health risk after supply suspension in tap water

Water supply suspension-restoration can occur frequently due to the overhauling of civil infrastructure in developing countries and the shutdown of commercial buildings during the pandemic. For comprehensive insights into the effects of water supply suspension-restoration, this study characterized the variations of the pathogen community composition of the tap water and their infection risk under different water supply scenarios. Metagenomic sequencing revealed a significant change of the human pathogen profiles, among which the most dominant pathogen changed from Pseudomonas aeruginosa (4.91%) to Acinetobacter johnsonii (0.59%). Furthermore, absolute quantification of pathogens by propidium-monoazide-qPCR revealed that the abundance of the three typical pathogens (Pseudomonas aeruginosa, Mycobacterium avium and Salmonella sp.) showed an increase of 2.44 log to 3.60 log immediately after water supply suspension-restoration and did not return to the normal level even after 2-h supply restoration, except for Pseudomonas aeruginosa. Quantitative microbial risk assessment suggested the infection risks of the three pathogens arising from direct utilization of tap water under stable water supply, including dermal exposure and oral intake, were all above the threshold of 10^-4, and evidently increased after water supply suspension-restoration. This study warns us against the risk induced by the pathogens in tap water, especially after water supply suspension-restoration.

Waterborne Infectious Diseases Associated with Exposure to Tropical Cyclonic Storms, United States, 1996-2018

In the United States, tropical cyclones cause destructive flooding that can lead to adverse health outcomes. Storm-driven flooding contaminates environmental, recreational, and drinking water sources, but few studies have examined effects on specific infections over time. We used 23 years of exposure and case data to assess the effects of tropical cyclones on 6 waterborne diseases in a conditional quasi-Poisson model. We separately defined storm exposure for windspeed, rainfall, and proximity to the storm track. Exposure to storm-related rainfall was associated with a 48% (95% CI 27%-69%) increase in Shiga toxin-producing Escherichia coli infections 1 week after storms and a 42% (95% CI 22%-62%) in increase Legionnaires' disease 2 weeks after storms. Cryptosporidiosis cases increased 52% (95% CI 42%-62%) during storm weeks but declined over ensuing weeks. Cyclones are a risk to public health that will likely become more serious with climate change and aging water infrastructure systems.

Contamination of Hotel Water Distribution Systems by Legionella Species: Environmental Surveillance in Campania Region, South Italy

The COVID-19 pandemic period was marked by the absence or reduced circulation of some infectious diseases. Legionellosis may have been affected by the prevention measures adopted to counter COVID-19. Legionellosis is a form of pneumonia interstitial that is normally transmitted via aerosol-containing bacteria (genus Legionella), that could be present in contaminated water sources and is often associated with travel and with staying in hotels. In this work, the data of the environmental surveys carried out by ARPA Campania in accommodation facilities since 2019 were analyzed for a better understanding of the dispersion patterns of L. pneumophila associated with the environment and to evaluate the variation of the data during the pandemic period. The aim was to provide a better understanding of Legionella at different geographic scales and to define a predictive epidemiological method. Results: In 2019, the Legionella genus contaminated 37.7% of all tourist facilities evaluated. In 2020, the Legionella genus contaminated 44.4% of all tourist facilities evaluated. In 2021, the Legionella genus contaminated 54.2% of all tourist facilities evaluated. Conclusions: Legionella pneumophila was the most prevalent species in our community, serogroup 1 was the most frequently isolated and the most implicated risk factor of contamination was the temperature of water in circulation.

Water Safety Plan, Monochloramine Disinfection and Extensive Environmental Sampling Effectively Control Legionella and Other Waterborne Pathogens in Nosocomial Settings: The Ten-Year Experience of an Italian Hospital

Legionella contamination control is crucial in healthcare settings where patients suffer an increased risk of disease and fatal outcome. To ensure an effective management of this health hazard, the accurate application of a hospital-specific Water Safety Plan (WSP), the choice of a suitable water disinfection system and an extensive monitoring program are required. Here, the ten-year experience of an Italian hospital is reported: since its commissioning, Legionellosis risk management has been entrusted to a multi-disciplinary Working Group, applying the principles of the World Health Organization's WSP. The disinfection strategy to prevent Legionella and other waterborne pathogens relies on the treatment of domestic hot water with a system ensuring the in situ production and dosage of monochloramine. An average of 250 samples/year were collected and analyzed to allow an accurate assessment of the microbiological status of water network. With the aim of increasing the monitoring sensitivity, in addition to the standard culture method, an optimized MALDI-ToF MS-based strategy was applied, allowing the identification of Legionella species and other relevant opportunistic pathogens. Data collected so far confirmed the effectiveness of this multidisciplinary approach: the fraction of positive samples never overcame 1% on a yearly basis and Legionnaires' Disease cases never occurred.

Estimating Waterborne Infectious Disease Burden by Exposure Route, United States, 2014

More than 7.15 million cases of domestically acquired infectious waterborne illnesses occurred in the United States in 2014, causing 120,000 hospitalizations and 6,600 deaths. We estimated disease incidence for 17 pathogens according to recreational, drinking, and nonrecreational nondrinking (NRND) water exposure routes by using previously published estimates. In 2014, a total of 5.61 million (95% credible interval [CrI] 2.97-9.00 million) illnesses were linked to recreational water, 1.13 million (95% CrI 255,000-3.54 million) to drinking water, and 407,000 (95% CrI 72,800-1.29 million) to NRND water. Recreational water exposure was responsible for 36%, drinking water for 40%, and NRND water for 24% of hospitalizations from waterborne illnesses. Most direct costs were associated with pathogens found in biofilms. Estimating disease burden by water exposure route helps direct prevention activities. For each exposure route, water management programs are needed to control biofilm-associated pathogen growth; public health programs are needed to prevent biofilm-associated diseases.

Initiating guidance values for novel biological stability parameters in drinking water to control regrowth in the distribution system

Nine novel biological stability parameters for drinking water have been developed recently. Here, we report data for these nine parameters in treated water from 34 treatment plants in the Netherlands to deduce guidance values for these parameters. Most parameters did not show a strong correlation with another biological stability parameter in the same sample, demonstrating that most parameters hold different information on the biological stability of drinking water. Furthermore, the novel biological stability parameters in treated water varied considerably between plants and five parameters in treated water were significantly lower for drinking water produced from groundwater than surface water. The maximum biomass concentration (MBC₇), cumulative biomass potential (CBP₁₄) from the biomass production potential test (BPP-W) and the total organic carbon concentration in treated water from groundwater were predictive parameters for HPC22 and Aeromonas regrowth in the distribution system. Guidance values of 8.6 ng ATP L^-1, 110 d·ng ATP L^-1 and 4.1 mg C L^-1 were deduced for these parameters, under which the HPC22 and Aeromonas numbers remain at regulatory level. The maximum biomass growth (MBG₇) from the BPP-W test, the particulate and/or high molecular organic carbon and the iron accumulation rate in treated water from surface water were predictive parameters for HPC22 and Aeromonas regrowth in the distribution system. Deduced guidance values for these biological stability parameters were 4.5 ng ATP L^-1, 47 μg C L^-1 and 0.34 mg Fe m^-2 day^-1, respectively. We conclude from our study that a multiple parameter assessment is required to reliable describe the biological stability of drinking water, that the biological stability of drinking water produced from groundwater is described with other parameters than the biological stability of drinking water produced from surface water, and that guidance values for predictive biological stability parameters were inferred under which HPC22 and Aeromonas regrowth is under control.

A Critical Review on the Factors that Influence Opportunistic Premise Plumbing Pathogens: From Building Entry to Fixtures in Residences

Residential buildings provide unique conditions for opportunistic premise plumbing pathogen (OPPP) exposure via aerosolized water droplets produced by showerheads, faucets, and tubs. The objective of this review was to critically evaluate the existing literature that assessed the impact of potentially enhancing conditions to OPPP occurrence associated with residential plumbing and to point out knowledge gaps. Comprehensive studies on the topic were found to be lacking. Major knowledge gaps identified include the assessment of OPPP growth in the residential plumbing, from building entry to fixtures, and evaluation of the extent of the impact of typical residential plumbing design (e.g., trunk and branch and manifold), components (e.g., valves and fixtures), water heater types and temperature setting of operation, and common pipe materials (copper, PEX, and PVC/CPVC). In addition, impacts of the current plumbing code requirements on OPPP responses have not been assessed by any study and a lack of guidelines for OPPP risk management in residences was identified. Finally, the research required to expand knowledge on OPPP amplification in residences was discussed.

Associations of household factors, hot water temperature, and chlorine residual with Legionella occurrence in single-family homes in New Jersey

Only 4 % of reported Legionnaires' disease (LD) cases are outbreak-associated and the remaining 96 % are sporadic, for which no known source of Legionella is identified. Although outbreaks of LD are linked to cooling towers, decorative fountains, spas and hot tubs, and other sources, the drivers of sporadic LD are less known. Residential premise plumbing is likely an important source of aerosol exposure and there are unique features of premise plumbing which could lead to proliferation of Legionella. A sampling study of Legionella in single-family homes was undertaken in NJ from 2020 to 2021 which included a household characteristic survey and collection of hot water temperature and chlorine residual during sampling. A total of 94 homeowners residing in owner-occupied, single-family units with individual hot water systems were recruited to participate through two mechanisms (1) Legionnaire's disease case-patients and (2) non-case volunteers from each NJ county. Among the 94 single-family homes sampled, 15 % had least one sample positive for Legionella by culture and 57 % had at least one sample with detection of Legionella DNA markers by PCR. Chlorine residual, hot water temperature, and season were independently associated with increased detection of Legionella in home water samples. There was limited or inconsistent evidence of the role of household characteristic factors in Legionella detection. This study identified season, insufficient chlorine residual and hot water temperature as risk factors for Legionella detection in single-family homes. Findings from this work can promote additional partnership between public health and water utilities in improving chlorine residuals in residential communities and educating homeowners on best practices for home water management.

Legionella pneumophila Risk from Air–Water Cooling Units Regarding Pipe Material and Type of Water

Legionellosis is a respiratory disease related to environmental health. There have been manifold studies of pipe materials, risk installations and legionellosis without considering the type of transferred water. The objective of this study was to determine the potential development of the causative agent Legionella pneumophila regarding air–water cooling units, legislative compliance, pipe material and type of water. Forty-four hotel units in Andalusia (Spain) were analysed with respect to compliance with Spanish health legislation for the prevention of legionellosis. The chi-square test was used to explain the relationship between material–water and legislative compliance, and a biplot of the first two factors was generated. Multiple correspondence analysis (MCA) was performed on the type of equipment, legislative compliance, pipe material and type of water, and graphs of cases were constructed by adding confidence ellipses by categories of the variables. Pipe material–type of water (p value = 0.29; p < 0.05) and legislative compliance were not associated (p value = 0.15; p < 0.05). Iron, stainless steel, and recycled and well water contributed the most to the biplot. MCA showed a global pattern in which lead, iron and polyethylene were well represented. Confidence ellipses around categories indicated significant differences among categories. Compliance with Spanish health legislation regarding the prevention and control of legionellosis linked to pipe material and type of water was not observed.

The prevalence of potential pathogens in ballast water and sediments of oceangoing vessels and implications for management

Ballast water and sediments can serve as prominent vectors for the widespread dispersal of pathogens between geographically distant areas. However, information regarding the diversity and distribution of the bacterial pathogens in ballast water and sediments is highly limited. In this study, using high-throughput sequencing and quantitative PCR, we investigated the composition and abundance of potential pathogens, and their associations with indicator microorganisms. We accordingly detected 48 potential bacterial pathogens in the assessed ballast water and sediments, among which there were significant differences in the compositions and abundances of pathogenic bacterial communities characterizing ballast water and sediments. Rhodococcus erythropolis, Bacteroides vulgatus, and Vibrio campbellii were identified as predominant pathogens in ballast water, whereas Pseudomonas stutzeri, Mycobacterium paragordonae, and Bacillus anthracis predominated in ballast sediments. Bacteroidetes, Vibrio alginolyticus, Vibrio parahaemolyticus, and Escherichia coli were generally detected with median values of 8.54 × 10³-1.22 × 10⁷ gene copies (GC)/100 mL and 1.16 × 10⁷-3.97 × 10⁹ GC/100 g in ballast water and sediments, respectively. Notably, the concentrations of Shigella sp., Staphylococcus aureus, and V. alginolyticus were significantly higher in ballast sediments than in the water. In addition, our findings tend to confirm that the indicator species specified by the International Maritime Organization (IMO) might underestimate the pathogen risk in the ballast water and sediments, as these bacteria were unable to predict some potential pathogens assessed in this study. In summary, this study provides a comprehensive insight into the spectrum of the potential pathogens that transferred by ship ballast tanks and emphasizes the need for the implementation of IMO convention on ballast sediment management.

Biofilm Control in Flow-Through Systems Using Polyvalent Phages Delivered by Peptide-Modified M13 Coliphages with Enhanced Polysaccharide Affinity

Eradication of biofilms that may harbor pathogens in water distribution systems is an elusive goal due to limited penetration of residual disinfectants. Here, we explore the use of engineered filamentous coliphage M13 for enhanced biofilm affinity and precise delivery of lytic polyvalent phages (i.e., broad-host-range phages lysing multiple host strains after infection). To promote biofilm attachment, we modified the M13 major coat protein (pVIII) by inserting a peptide sequence with high affinity for Pseudomonas aeruginosa (P. aeruginosa) extracellular polysaccharides (commonly present on the surface of biofilms in natural and engineered systems). Additionally, we engineered the M13 tail fiber protein (pIII) to contain a peptide sequence capable of binding a specific polyvalent lytic phage. The modified M13 had 102- and 5-fold higher affinity for P. aeruginosa-dominated mixed-species biofilms than wildtype M13 and unconjugated polyvalent phage, respectively. When applied to a simulated water distribution system, the resulting phage conjugates achieved targeted phage delivery to the biofilm and were more effective than polyvalent phages alone in reducing live bacterial biomass (84 vs 34%) and biofilm surface coverage (81 vs 22%). Biofilm regrowth was also mitigated as high phage concentrations induced residual bacteria to downregulate genes associated with quorum sensing and extracellular polymeric substance secretion. Overall, we demonstrate that engineered M13 can enable more accurate delivery of polyvalent phages to biofilms in flow-through systems for enhanced biofilm control.

Isolation of nontuberculous mycobacteria species from different water sources: a study of six hospitals in Tehran, Iran

Purpose

Nontuberculous mycobacteria (NTM) are ubiquitous bacteria that are naturally resistant to disinfectants and antibiotics and can colonize systems for supplying drinking water. Therefore, this study aimed to evaluate the prevalence of NTM in the drinking water of six hospitals in Tehran, Iran.

Methods

Totally, 198 water samples were collected. Each water sample was filtered via a membrane filter with a pore size of 0.45 µm and then decontaminated by 0.005% cetylpyridinium chloride. The membrane filters were incubated on two Lowenstein-Jensen media at 25 °C and 37 °C for 8 weeks. The positive cultures were identified with phenotypic tests, and then NTM species were detected according to the hsp65, rpoB, and 16S rDNA genes. Drug susceptibility testing (DST) was also carried out.

Results

Overall, 76 (40.4%) of the isolates were slowly growing mycobacteria (SGM) and 112 (59.6%) of the ones were rapidly growing mycobacteria (RGM). The most common NTM were Mycobacterium aurum, M. gordonae, M. phocaicum, M. mucogenicum, M. kansasii, M. simiae, M. gadium, M. lentiflavum, M. fortuitum, and M. porcinum. Among these 188 samples, NTM ranged from 1 to > 300 colony-forming unit (CFU) /500 mL, with a median of 182 CFU/500 mL. In the infectious department of all hospitals, the amount of CFU was higher than in other parts of the hospitals. The DST findings in this study indicated the diversity of resistance to different drugs. Among RGM, M. mucogenicum was the most susceptible isolate; however, M. fortuitum showed a different resistance pattern. Also, among SGM isolates, M. kansasii and M. simiae, the diversity of DST indicated.

Conclusions

The current study showed NTM strains could be an important component of hospital water supplies and a possible source of nosocomial infections according to the CFU reported in this study. The obtained findings also help clarify the dynamics of NTM variety and distribution in the water systems of hospitals in the research area.

The AhR ligand phthiocol and vitamin K analogs as Pseudomonas aeruginosa quorum sensing inhibitors

The aryl hydrocarbon receptor (AhR) protein senses microbial-secreted metabolites to trigger the host's innate immune system. The Pseudomonas quinolone signal (PQS) and Mycobacterium tuberculosis (MTb) metabolite phthiocol (Pht) are both ligands of AhR with similar chemical structures. As PQS is an essential quorum-sensing molecule that regulates a wide range of virulence factors in Pseudomonas aeruginosa, we hypothesized that Pht and its analogs are potential P. aeruginosa quorum-sensing inhibitors (QSIs) with immune-modulating functions. In this study, we demonstrated that Pht was able to inhibit the P. aeruginosa pqs QS system and reduce both biofilm formation and the production of pyocyanin. Molecular docking analysis suggested that Pht competes with PQS at the binding site of its receptor, PqsR. An electrophoretic mobility shift assay confirmed the Pht-PqsR interaction and showed that Pht attenuated PqsR from binding to the pqsA promoter. Proteomic analysis showed that synthesis of the key pqs QS proteins decreased upon the addition of Pht to the bacterial cultures. Furthermore, Pht analogs vitamins K1 (Phylloquinone), K2 (Menaquinones), and K3 (Menadione) were also showed to inhibit the P. aeruginosa pqs QS system while able to activate the AhR signaling pathways. Our study suggests that the AhR ligands Pht and its vitamin K analogs are promising QSIs for the alternative treatment of P. aeruginosa infections.

Intercellular communication and social behaviors in mycobacteria

Cell-to-cell communication is a fundamental process of bacteria to exert communal behaviors. Sputum samples of patients with cystic fibrosis have often been observed with extensive mycobacterial genetic diversity. The emergence of heterogenic mycobacterial populations is observed due to subtle changes in their morphology, gene expression level, and distributive conjugal transfer (DCT). Since each subgroup of mycobacteria has different hetero-resistance, they are refractory against several antibiotics. Such genetically diverse mycobacteria have to communicate with each other to subvert the host immune system. However, it is still a mystery how such heterogeneous strains exhibit synchronous behaviors for the production of quorum sensing (QS) traits, such as biofilms, siderophores, and virulence proteins. Mycobacteria are characterized by division of labor, where distinct sub-clonal populations contribute to the production of QS traits while exchanging complimentary products at the community level. Thus, active mycobacterial cells ensure the persistence of other heterogenic clonal populations through cooperative behaviors. Additionally, mycobacteria are likely to establish communication with neighboring cells in a contact-independent manner through QS signals. Hence, this review is intended to discuss our current knowledge of mycobacterial communication. Understanding mycobacterial communication could provide a promising opportunity to develop drugs to target key pathways of mycobacteria.

A sequential utilization of the UV-A (365 nm) fluence rate for disinfection of water, contaminated with Legionella pneumophila and Legionelladumoffii

Legionella species are the etiological agent of Legionnaires' disease, a pathology easily contracted from water circuits and by the inhalation of aerosol droplets. This bacterium mainly proliferates in water: Legionella pneumophila is the most commonly isolated specie in water environments and consequently in water system, although further Legionella species have frequently been isolated, including Legionella dumoffii. The simultaneous presence of the two species in the water system can therefore lead to the simultaneous infection of several people, giving rise to harmful outbreaks. Ultraviolet inactivation of waterborne microorganisms offers a rapid and effective treatment technique and recently is getting more attention mostly to eliminate unsafe level of contamination. To tackle the issue, the inactivation of the two species of Legionella spp., namely L. pneumophila and L. dumoffii, by means of UV-A light emitting diodes (UV-A LED) system is explored. We used a commercially available UV-A LED at 365 nm wavelength, and the UV-A dose is given incrementally to the Legionellae with a concentration of 106 CFU/mL in 0.9% NaCl (aq) solution. In this study, with a UV-A-dose of 1700 mJ/cm2, the log-reduction of 3-log (99.9% inactivation) for L. pneumophila and 2.1-log (99.1% inactivation) for L. dumoffii of the contaminated water are achieved. The Electrical Energy per Order (EEO) is evaluated and showed this system is more economic and efficient in comparison with UV-C and UV-B LEDs. Following the support of this preliminary study with additional tests, aiming to validate the technology, we expect this device may be installed in water plants such as cooling systems or any water purification station in either industrial or home scales to reduce the risk of this infectious disease, preventing consumers' health.

It’s a Long Way to the Tap: Microbiome and DNA-Based Omics at the Core of Drinking Water Quality

Microbial communities interact with us and affect our health in ways that are only beginning to be understood. Microorganisms have been detected in every ecosystem on Earth, as well as in any built environment that has been investigated. Drinking water sources, drinking water treatment plants and distribution systems provide peculiar microbial ecological niches, dismantling the belief of the “biological simplicity” of drinking water. Nevertheless, drinking water microbiomes are understudied compared to other microbiomes. Recent DNA sequencing and meta-omics advancements allow a deeper understanding of drinking water microbiota. Thus, moving beyond the limits of day-to-day testing for specific pathogenic microbes, new approaches aim at predicting microbiome changes driven by disturbances at the macro-scale and overtime. This will foster an effective and proactive management of water sources, improving the drinking water supply system and the monitoring activities to lower public health risk. Here, we want to give a new angle on drinking water microbiome research. Starting from a selection of 231 scientific publications on this topic, we emphasize the value of biodiversity in drinking water ecosystems and how it can be related with industrialization. We then discuss how microbiome research can support sustainable drinking water management, encouraging collaborations across sectors and involving the society through responsible research and innovation.

Detection of Pseudomonas aeruginosa Serogroup G Using Real-Time PCR for Novel Target Genes Identified Through Comparative Genomics

Accurate serotyping is essential for effective infection control. Pseudomonas aeruginosa serogroup G is one of the most common serogroups found in water. Conventional serotyping methods are not standardized and have several shortcomings. Therefore, a robust method for rapidly identifying P. aeruginosa serotypes is required. This study established a real-time PCR method for identifying P. aeruginosa serogroup G strains using novel target gene primers based on comparative genomic analysis. A total of 343 genome sequences, including 16 P. aeruginosa serogroups and 67 other species, were analyzed. Target genes identified were amplified using real-time PCR for detecting P. aeruginosa serogroup G strains. Eight serogroup G genes, PA59_01276, PA59_01887, PA59_01888, PA59_01891, PA59_01894, PA59_04268, PA59_01892, and PA59_01896, were analyzed to determine specific targets. A real-time fluorescence quantitative PCR method, based on the novel target PA59_01276, was established to detect and identify serogroup G strains. The specificity of this method was confirmed using P. aeruginosa serogroups and non-P. aeruginosa species. The sensitivity of this real-time PCR method was 4 × 10² CFU/mL, and it could differentiate and detect P. aeruginosa serogroup G in the range of 4.0 × 10³–4.0 × 10⁸ CFU/mL in artificially contaminated drinking water samples without enrichment. The sensitivity of these detection limits was higher by 1–3 folds compared to that of the previously reported PCR methods. In addition, the G serum group was accurately detected using this real-time PCR method without interference by high concentrations of artificially contaminated serum groups F and D. These results indicate that this method has high sensitivity and accuracy and is promising for identifying and rapidly detecting P. aeruginosa serogroup G in water samples. Moreover, this research will contribute to the development of effective vaccines and therapies for infections caused by multidrug-resistant P. aeruginosa.

The role of pipe biofilms on dissemination of viral pathogens and virulence factor genes in a full-scale drinking water supply system

Water is an important medium for virus transmission and viral pathogens are increasingly appreciated as a significant water safety issue. However, the effect of pipe biofilms on viral pathogens remains unclear. This research aimed to investigate the dissemination of viruses in a full-scale drinking water supply system (DWSS) and the effect of pipe biofilms on viral pathogens in bulking water. Viral pathogens, pathogenic viral hosts, and viral virulence factors (VFs) were found to disseminate from source water to tap water. The proportion of virus and viral VFs in the biofilm was far less than that in water. The contribution of biofilms in pipe wall to viruses and viral VFs in bulking water was less than 4%, and viruses in the biofilm had no obvious effect on pathogenic viruses in water. Dominant viruses carrying VFs changed from Cyanobacteria virus to Mycobacterium virus after advanced water treatment. Mycobacterium and organics were identified as the key factors influencing composition and abundance of viral VFs, which could explain 41.1% of the variation in viral virulence in the water supply system. Host bacteria and organics may be used as the key targets to control the risk of viruses in DWSSs.

Potential probiotic approaches to control Legionella in engineered aquatic ecosystems

Opportunistic pathogens belonging to the genus Legionella are among the most reported waterborne-associated pathogens in industrialized countries. Legionella colonize a variety of engineered aquatic ecosystems and persist in biofilms where they interact with a multitude of other resident microorganisms. In this review, we assess how some of these interactions could be used to develop a biological-driven “probiotic” control approach against Legionella. We focus on: (i) mechanisms limiting the ability of Legionella to establish and replicate within some of their natural protozoan hosts; (ii) exploitative and interference competitive interactions between Legionella and other microorganisms; and (iii) the potential of predatory bacteria and phages against Legionella. This field is still emergent, and we therefore specifically highlight research for future investigations, and propose perspectives on the feasibility and public acceptance of a potential probiotic approach.

Insights into effects of algae on decay and distribution of bacterial pathogens in recreational water: Implications for microbial risk management

The decay and distribution of bacterial pathogens in water is an important information for the health risk assessment to guide water safety management, and suspended algae might affect bacterial pathogens in water. This study established microcosms to investigate the effects of algae-related factors on the representative indicators and opportunistic pathogen species in water. We found that suspended algae increased the persistence of targeted species by 1-2 orders of magnitude of concentrations compared to microcosms without algae; and the effect of algae on microbial survival was affected by water nutrient levels (i.e., carbon, nitrogen and phosphorus), as the increased microbial persistence were correlated to the increased algae concentrations with more nutrient supplies. Moreover, decay and distribution profiles of representative species were determined. The three opportunistic pathogen species (Pseudomonas aeruginosa, Aeromonas hydrophila and Staphylococcus aureus) showed lower decay rates (0.82-0.98/day, 0.76-0.98/day, 0.63-0.87/day) largely affected by algae-related factors, while the enteric species (Escherichia coli and Enterococcus faecalis) had higher decay rates (0.94-1.31/day, 0.89-1.21/day) with little association with algae, indicating the propensity for attachment to algae is an important parameter in microbial fate. Together results suggest suspended algae played an evident role in the decay and distribution of bacterial pathogens, providing important implications regarding microbial safety in recreational water.

Tenets of a holistic approach to drinking water-associated pathogen research, management, and communication

In recent years, drinking water-associated pathogens that can cause infections in immunocompromised or otherwise susceptible individuals (henceforth referred to as DWPI), sometimes referred to as opportunistic pathogens or opportunistic premise plumbing pathogens, have received considerable attention. DWPI research has largely been conducted by experts focusing on specific microorganisms or within silos of expertise. The resulting mitigation approaches optimized for a single microorganism may have unintended consequences and trade-offs for other DWPI or other interests (e.g., energy costs and conservation). For example, the ecological and epidemiological issues characteristic of Legionella pneumophila diverge from those relevant for Mycobacterium avium and other nontuberculous mycobacteria. Recent advances in understanding DWPI as part of a complex microbial ecosystem inhabiting drinking water systems continues to reveal additional challenges: namely, how can all microorganisms of concern be managed simultaneously? In order to protect public health, we must take a more holistic approach in all aspects of the field, including basic research, monitoring methods, risk-based mitigation techniques, and policy. A holistic approach will (i) target multiple microorganisms simultaneously, (ii) involve experts across several disciplines, and (iii) communicate results across disciplines and more broadly, proactively addressing source water-to-customer system management.

Nondestructive 3D imaging and quantification of hydrated biofilm matrix by confocal Raman microscopy coupled with non-negative matrix factorization

Biofilms are ubiquitous in natural and engineered environments and of great importance in drinking water distribution and biological wastewater treatment systems. Simultaneously acquiring the chemical and structural information of the hydrated biofilm matrix is essential for the cognition and regulation of biofilms in the environmental field. However, the complexity of samples and the limited approaches prevent a holistic understanding of the biofilm matrix. In this work, an approach based on the confocal Raman mapping technique integrated with non-negative matrix factorization (NMF) analysis was developed to probe the hydrated biofilm matrix in situ. The flexibility of the NMF analysis was utilized to subtract the undesired water background signal and resolve the meaningful biological components from Raman spectra of the hydrated biofilms. Diverse chemical components such as proteins, bacterial cells, glycolipids and polyhydroxyalkanoates (PHA) were unraveled within the distinct Pseudomonas spp. biofilm matrices, and the corresponding 3-dimensional spatial organization was visualized and quantified. Of these components, glycolipids and PHA were unique to the P. aeruginosa and P. putida biofilm matrix, respectively. Furthermore, their high abundances in the lower region of the biofilm matrix were found to be related to the specific physiological functions and surrounding microenvironments. Overall, the results demonstrate that our NMF Raman mapping method could serve as a powerful tool complementary to the conventional approaches for identifying and visualizing the chemical components in the biofilm matrix. This work may facilitate the online characterization of the biofilm matrix widely present in the environment and advance the fundamental understanding of biofilm.

Cupriavidus spp and other waterborne organisms in healthcare water systems across the United Kingdom

BACKGROUND

Cupriavidus pauculus is a rare clinical pathogen with cases having been linked to contaminated hospital water systems. An outbreak of three cases of C. pauculus and other waterborne organisms was reported in a Glasgow hospital in 2018.

AIMS

The aim of this study was to determine whether Cupriavidus spp are present in hospital water systems elsewhere in Scotland and the UK and to ascertain the optimal laboratory methodology for detection. We also sought to establish where in the water system these organisms are detected and whether a selective media could be developed for isolation. In addition, we tested water samples for the presence of other Gram negative waterborne organisms.

METHODS

Water samples were received from ten UK NHS hospitals and from various parts of the water system. Isolates were plated on to TSA and Pseudomonas Isolation Agar and further identified using MALDI-TOF and 16S PCR FINDINGS: Cupriavidus spp. were detected in four of ten hospitals tested and all five isolates were from the periphery of the water system. All hospitals had evidence of other OPPPs. Cupriavidus spp. were identified using TSA, with some isolates growing on Pseudomonas isolation agar; as such they may be inadvertently be detected when testing water specifically for Pseudomonas aeruginosa.

CONCLUSION

This study demonstrates that isolation of Cupriavidus spp. was not unique to the Glasgow incident, these bacteria being present in hospital water systems elsewhere in the UK. We therefore recommend water testing in response to clinical cases. Consideration should also be given to water testing following bacteraemias due to other rare and unusual water borne pathogens.

Impact of pipe material and chlorination on the biofilm structure and microbial communities

Pipe material and residual chlorine are key factors for the drinking water distribution system, and understanding the biofilm ecosystem is vital for water quality safeguard. The aim of our study was to determine the influence of pipe materials (ductile iron, steel, polyethylene) and chlorination on the biofilm structure and microbial community, as shown by the physicochemical properties, extracellular polymeric substances (EPS) structural characteristics, bacterial community composition, and functional traits. EPS spatial properties were studied based on a semi-quantitative confocal laser scanning microscope (CLSM) description. Regarding the impact of chlorination, residule chlorine (1.0 ± 0.3 mg L^-1 free chlorine) could inhibit the bacteria colonization, and initiate a potential response to external disinfectants revealed by the EPS spatial distribution changes and communities variation compared to unchlorinated system. Regarding the impact of pipe material, polyethylene (PE) biofilms displayed lower biomass, loose zoogloea structure, lower proteins and polysaccharides content, and poor microbial diversity in contrast to ductile iron and steel biofilms. Pipe material was the more possible driving factor of the biofilm community composition compared to the chlorination based on principal coordinates analysis (PCoA) and permutational multivariate analysis of variance (PERMANOVA). Actinobacteria was dominant in the PE biofilms (45.57%-83.32%), while Alphaproteobacteria (34.30%-73.22%) and Gammaproteobacteria (6.46%-36.82%) were the major classes in the steel and ductile iron biofilms. The genus Rhodococcus was predominant in the PE biofilms. Rhodococcus, Pseudomonas, and Sphingomonas seemed to have a better growth advantage in the chlorinated system and display a stronger disinfectant resistance. Functional sketch prediction indicated the potential impact of pipe material and chlorination on functional pathway abundnce, possible functional pathways associated with infectious disease included. This study provides insights into the impact of pipe material and chlorination on biofilm structure and microbial community and might help to develop monitoring or maintenance strategies to protect the biosafety of the drinking water.

Characterizing the premise plumbing microbiome in both water and biofilms of a 50-year-old building

The premise plumbing portion of drinking water distribution systems (DWDS) has several characteristics that may favor microbial growth in the form of biofilms. These microbial communities are implicated as infectious sources for the spread of opportunistic waterborne pathogens by supporting their complex ecology and transmission through DWDS outlets to susceptible individuals. However, there is limited understanding of the drinking water biofilms in real premise plumbing networks due to challenges with accessibility. Using a combination of culture-dependent and culture-independent approaches, this study comprehensively characterized the premise plumbing microbiome of a 50-year-old university building, inclusive of water and biofilm samples. Microbial diversity in the water samples were more taxonomically diverse in comparison to the mature drinking water biofilms, which were dominated with biofilm-formers and opportunistic pathogens, such as Mycobacterium spp. A model opportunistic pathogen, Legionella spp., was only detectable in water samples using quantitative PCR but could not be detected in any of the drinking water biofilms using either qPCR or culture-dependent approaches, highlighting the limitations of detection methods in these environments. This study presents preliminary findings on the microbial dynamics and complexity in premise plumbing networks, which may support public health management and the development of strategies to eliminate microbial risks to human health.

Legionella: A Promising Supplementary Indicator of Microbial Drinking Water Quality in Municipal Engineered Water Systems

Opportunistic pathogens (OPs) are natural inhabitants and the predominant disease causative biotic agents in municipal engineered water systems (EWSs). In EWSs, OPs occur at high frequencies and concentrations, cause drinking-water-related disease outbreaks, and are a major factor threatening public health. Therefore, the prevalence of OPs in EWSs represents microbial drinking water quality. Closely or routinely monitoring the dynamics of OPs in municipal EWSs is thus critical to ensuring drinking water quality and protecting public health. Monitoring the dynamics of conventional (fecal) indicators (e.g., total coliforms, fecal coliforms, and Escherichia coli) is the customary or even exclusive means of assessing microbial drinking water quality. However, those indicators infer only fecal contamination due to treatment (e.g., disinfection within water utilities) failure and EWS infrastructure issues (e.g., water main breaks and infiltration), whereas OPs are not contaminants in drinking water. In addition, those indicators appear in EWSs at low concentrations (often absent in well-maintained EWSs) and are uncorrelated with OPs. For instance, conventional indicators decay, while OPs regrow with increasing hydraulic residence time. As a result, conventional indicators are poor indicators of OPs (the major aspect of microbial drinking water quality) in EWSs. An additional or supplementary indicator that can well infer the prevalence of OPs in EWSs is highly needed. This systematic review argues that Legionella as a dominant OP-containing genus and natural inhabitant in EWSs is a promising candidate for such a supplementary indicator. Through comprehensively comparing the behavior (i.e., occurrence, growth and regrowth, spatiotemporal variations in concentrations, resistance to disinfectant residuals, and responses to physicochemical water quality parameters) of major OPs (e.g., Legionella especially L. pneumophila, Mycobacterium, and Pseudomonas especially P. aeruginosa), this review proves that Legionella is a promising supplementary indicator for the prevalence of OPs in EWSs while other OPs lack this indication feature. Legionella as a dominant natural inhabitant in EWSs occurs frequently, has a high concentration, and correlates with more microbial and physicochemical water quality parameters than other common OPs. Legionella and OPs in EWSs share multiple key features such as high disinfectant resistance, biofilm formation, proliferation within amoebae, and significant spatiotemporal variations in concentrations. Therefore, the presence and concentration of Legionella well indicate the presence and concentrations of OPs (especially L. pneumophila) and microbial drinking water quality in EWSs. In addition, Legionella concentration indicates the efficacies of disinfectant residuals in EWSs. Furthermore, with the development of modern Legionella quantification methods (especially quantitative polymerase chain reactions), monitoring Legionella in ESWs is becoming easier, more affordable, and less labor-intensive. Those features make Legionella a proper supplementary indicator for microbial drinking water quality (especially the prevalence of OPs) in EWSs. Water authorities may use Legionella and conventional indicators in combination to more comprehensively assess microbial drinking water quality in municipal EWSs. Future work should further explore the indication role of Legionella in EWSs and propose drinking water Legionella concentration limits that indicate serious public health effects and require enhanced treatment (e.g., booster disinfection).

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

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

Opportunistic pathogens exhibit distinct growth dynamics in rainwater and tap water storage systems

Opportunistic pathogens (OPs) are emerging microbial contaminants in engineered water systems, yet their growth potential in rainwater systems has not been evaluated. The purpose of this study was to compare the growth dynamics of bacterial OPs and related genera (Pseudomonas aeruginosa, Legionella spp., L. pneumophila, Mycobacterium spp., and M. avium), two amoebal hosts (Acanthamoeba spp. and Vermamoeba vermiformis), and the fecal indicator Escherichia coli in simulated rainwater and tap water storage systems (SWSSs). Quantitative polymerase chain reaction (q-PCR) analysis of target microorganisms in SWSS influents and effluents demonstrated that P. aeruginosa and Legionella thrived in rainwater, but not in tap water. V. vermiformis proliferated in both rainwater and tap water polyvinyl chloride (PVC) SWSSs, while mycobacteria were largely absent in rainwater SWSSs. Tank materials exerted stronger influence on target microorganisms in rainwater SWSSs relative to tap water SWSSs, with species-specific responses noted in bulk water and biofilm. For instance, P. aeruginosa and V. vermiformis had the highest gene copy numbers in PVC rainwater SWSS effluents and biofilm, while Legionella peaked in stainless steel rainwater SWSS effluents and PVC rainwater SWSS biofilm. These results highlighted the OP contamination risks in rainwater storage systems and provided insights into rainwater system design and operation in terms of OP control.

Bacterial Long-Range Warfare: Aerial Killing of Legionella pneumophila by Pseudomonas fluorescens

Legionella pneumophila, the causative agent of Legionnaires’ disease, is mostly found in man-made water systems and is one of the most closely monitored waterborne pathogens. With the aim of finding natural ways to control waterborne pathogens and thus further reduce the impact of disinfection by-products on human health, some studies have demonstrated the ability of bacteria to kill Legionella through the production of secondary metabolites or antimicrobial compounds. Here, we describe an unexpected growth inhibition of L. pneumophila when exposed to a physically separated strain of Pseudomonas fluorescens, designated as MFE01. Most of the members of the Legionellaceae family are sensitive to the volatile substances emitted by MFE01, unlike other bacteria tested. Using headspace solid-phase microextraction GC-MS strategy, a volatilome comparison revealed that emission of 1-undecene, 2-undecanone, and 2-tridecanone were mainly reduced in a Tn5-transposon mutant unable to inhibit at distance the growth of L. pneumophila strain Lens. We showed that 1-undecene was mainly responsible for the inhibition at distance in vitro, and led to cell lysis in small amounts, as determined by gas chromatography-mass spectrometry (GC-MS). Collectively, our results provide new insights into the mode of action of bacterial volatiles and highlight them as potent anti-Legionella agents to focus research on novel strategies to fight legionellosis.

IMPORTANCE Microbial volatile compounds are molecules whose activities are increasingly attracting the attention of researchers. Indeed, they can act as key compounds in long-distance intrakingdom and interkingdom communication, but also as antimicrobials in competition and predation. In fact, most studies to date have focused on their antifungal activities and only a few have reported on their antibacterial properties. Here, we describe that 1-undecene, naturally produced by P. fluorescens, is a volatile with potent activity against bacteria of the genus Legionella. In small amounts, it is capable of inducing cell lysis even when the producing strain is physically separated from the target. This is the first time that such activity is described. This molecule could therefore constitute an efficient compound to counter bacterial pathogens whose treatment may fail, particularly in pulmonary diseases. Indeed, inhalation of these volatiles should be considered as a possible route of therapy in addition to antibiotic treatment.

Citizen science chlorine surveillance during the Flint, Michigan federal water emergency

Rising incidence of waterborne diseases including Legionellosis linked to low chlorine residuals in buildings and the availability of inexpensive testing options, create an opportunity for citizen science chorine monitoring to complement sampling done by water utilities. University researchers and Flint residents coordinated a citizen science chlorine surveillance campaign in Flint, Michigan in 2015-19, that helped expose the nature of two deadly Legionnaires Disease outbreaks in 2014-2015 during the Flint Water Crisis and progress of system recovery during the Federal emergency. Results obtained with an inexpensive color wheel were in agreement with a digital colorimeter (R² =0.99; p = 2.81 × 10^-21) at 15 sites geographically distributed across Flint. Blinded tests revealed good agreement between official (n = 2051) and citizen (n = 654) data in terms of determining whether regulatory guidelines for chlorine were met, but a discovery that the citizen data were statistically lower than the city's (p<0.00001) especially in warm summer months led to recommendations for increased flushing of service lines before measurements. This work suggests that expanded citizen surveillance of chlorine, site specific flushing advice, and guidance on decisions about water heater set point could help consumers reduce Legionella risks in their homes. Citizen science initiatives for chlorine monitoring offer a unique opportunity for mutually beneficial collaborations between consumers and utilities to reduce the main source of waterborne disease in developed countries.

Non-thermal plasma-based inactivation of bacteria in water using a microfluidic reactor

Failure of conventional water treatment systems may lead to the contamination of water sources, which can cause outbreaks of waterborne healthcare associated infections. Advanced oxidation processing by non-thermal plasma has the potential to treat water without the addition of chemicals. Antibiotic resistant Pseudomonas aeruginosa and Escherichia coli were chosen to investigate the use of non-thermal plasma generated in a microfluidic reactor to disinfect bacteria contaminated water. The microfluidic reactor used in this study utilized a dielectric barrier discharge, in a gas-liquid phase annular flow regime. Microbiological analysis of water inoculated with P. aeruginosa and E. coli was carried out before and after plasma treatment. Using air as the carrier gas, effective disinfection of water was achieved. At the lowest flow rate (35 µL/min), P. aeruginosa and E. coli viability were drastically reduced, with an approximate 8 log maximum decrease in viability following an estimated residence time of 5 s of plasma treatment. Scanning electron microscopy indicated changes in cell morphology due to the plasma treatment. Live/Dead assays revealed that the membranes of the cells had been damaged after plasma treatment. This work demonstrated that non-thermal plasma has the potential to disinfect against microbial contamination in water.

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

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

Seasonal host and ecological drivers may promote restricted water as a viral vector

In climates with seasonally limited precipitation, terrestrial animals congregate at high densities at scarce water sources. We hypothesize that viruses can exploit the recurrence of these diverse animal congregations to spread. In this study, we test the central prediction of this hypothesis - that viruses employing this transmission strategy remain stable and infectious in water. Equid herpesviruses (EHVs) were chosen as a model as they have been shown to remain stable and infectious in water for weeks under laboratory conditions. Using fecal data from wild equids from a previous study, we establish that EHVs are shed more frequently by their hosts during the dry season, increasing the probability of water source contamination with EHV. We document the presence of several strains of EHVs present in high genome copy number from the surface water and sediments of waterholes sampled across a variety of mammalian assemblages, locations, temperatures and pH. Phylogenetic analysis reveals that the different EHV strains found exhibit little divergence despite representing ancient lineages. We employed molecular approaches to show that EHVs shed remain stable in waterholes with detection decreasing with increasing temperature in sediments. Infectivity experiments using cell culture reveals that EHVs remain infectious in water derived from waterholes. The results are supportive of water as an abiotic viral vector for EHV.