Economic and health impacts associated with a Salmonella Typhimurium drinking water outbreak-Alamosa, CO, 2008

The Economic Burden of Non-Typhoidal Salmonella and Invasive Non-Typhoidal Salmonella Infection: A Systematic Literature Review

Non-typhoidal Salmonella (NTS) infection and invasive non-typhoidal Salmonella (iNTS) infection cause a significant global health and economic burden. This systematic review aims to investigate the reported economic burden of NTS and iNTS infection, identify research gaps, and suggest future research directions. Data from PubMed and Embase databases up to April 2022 were reviewed, and articles were screened based on predefined criteria. Cost data were extracted, categorized into direct medical costs (DMCs), direct non-medical costs (DNMCs), and indirect costs (ICs), and converted into US dollars (year 2022). Data primarily originated from high-income countries (37 out of 38), with limited representation from Africa and resource-limited settings. For inpatients, DMCs were the primary cost driver for both NTS and iNTS illnesses, with estimates ranging from USD 545.9 (Taiwan, a region of China) to USD 21,179.8 (Türkiye) for NTS and from USD 1973.1 (Taiwan, a region of China) to USD 32,507.5 (United States of America) for iNTS per case. DNMCs and ICs varied widely across studies. Although study quality improved over time, methodological differences persisted. This review underscores the lack of economic data on NTS and iNTS in resource-limited settings. It also highlights the need for economic burden data in resource-limited settings and a standardized approach to generate global datasets, which is critical for informing policy decisions, especially regarding future vaccines.

Salmonella Bloodstream Infections

Salmonella is a major foodborne pathogen of both animals and humans. This bacterium is responsible for considerable morbidity and mortality world-wide. Different serovars of this genus cause diseases ranging from self-limiting gastroenteritis to a potentially fatal systemic disease known as enteric fever. Gastrointestinal infections with Salmonella are usually self-limiting and rarely require medical intervention. Bloodstream infections, on the other hand, are often fatal even with hospitalization. This review describes the routes and underlying mechanisms of the extraintestinal dissemination of Salmonella and the chronic infections that sometimes result. It includes information on the pathogenicity islands and individual virulence factors involved in systemic dissemination as well as a discussion of the host factors that mediate susceptibility. Also, the major outbreaks of invasive Salmonella disease in the tropics are described.

Foodborne Illness Outbreaks Reported to National Surveillance, United States, 2009–2018

Foodborne outbreaks reported to national surveillance systems represent a subset of all outbreaks in the United States; not all outbreaks are detected, investigated, and reported. We described the structural factors and outbreak characteristics of outbreaks reported during 2009–2018. We categorized states (plus DC) as high (highest quintile), middle (middle 3 quintiles), or low (lowest quintile) reporters on the basis of the number of reported outbreaks per 10 million population. Analysis revealed considerable variation across states in the number and types of foodborne outbreaks reported. High-reporting states reported 4 times more outbreaks than low reporters. Low reporters were more likely than high reporters to report larger outbreaks and less likely to implicate a setting or food vehicle; however, we did not observe a significant difference in the types of food vehicles identified. Per capita funding was strongly associated with increased reporting. Investments in public health programming have a measurable effect on outbreak reporting.

A Model System for Sensitive Detection of Viable E. coli Bacteria Combining Direct Viability PCR and a Novel Microarray-Based Detection Approach

We established an innovative approach that included direct, viability, and nested PCR for rapid and reliable identification of the fecal indicator organism Escherichia coli (E. coli). Direct PCR enabled successful amplification of the target uidA gene, omitting a prior DNA isolation or purification step. Furthermore, we applied viability PCR (v-PCR) to ensure the detection of only relevant viable bacterial cells. The principle involves the binding of propidium monoazide (PMA), a selective nucleic acid intercalating dye, to accessible DNA of heat killed bacteria cells and, consequently, allows viable and heat killed E. coli cells to be discriminated. To ensure high sensitivity, direct v-PCR was followed by a nested PCR step. The resulting amplicons were analyzed by a rapid 30 min microarray-based DNA hybridization assay for species-specific DNA detection of E. coli. A positive signal was indicated by enzymatically generated silver nanoparticle deposits, which served as robust endpoint signals allowing an immediate visual readout. The presented novel protocol allows the detection of 1 × 101 viable E. coli cells per PCR run.

Prevalence of fluoroquinolone-resistant Salmonella serotypes in Iran: a meta-analysis

The present study was conducted to investigate the antimicrobial susceptibility profiles of Salmonella serotypes, especially fluoroquinolone-resistant strains, recovered from clinical samples in Iran. A full electronic search using related keywords was conducted in Persian and English languages in ISI Web of Knowledge, PubMed, Scopus, Google Scholar and the Scientific Information Database (SID) search engines to find papers published between 1983 and 1 July 2019. According to the inclusion and exclusion criteria, 46 eligible articles were selected for the final analysis out of the initial 13,186 studies retrieved. The pooled prevalence of quinolone-resistant Salmonella serotypes in clinical specimens in Iran was 2.9% to ciprofloxacin and 48.1% to nalidixic acid. Additional data on antibiotic resistance was as follows: 54.3% to tetracycline, 50.6% to ceftizoxime, 50.2% to streptomycin, 37.9% to ampicillin, 36.5% to kanamycin, 33.5% to trimethoprim-sulfamethoxazole, 27.2% to chloramphenicol, 19.1% to cephalothin, 8.8% to ceftriaxone, 7.6% to cefotaxime, 7.4% to aztreonam, 7.2% to gentamicin, 7% to cefepime, 6.8% to ceftazidime, 5.8% to cefixime, 2.7% to imipenem and 2.2% to meropenem. Findings of the present study showed a rising trend of resistance to the drugs of choice for the treatment of Salmonella infections, i.e. ampicillin, chloramphenicol and trimethoprim-sulfamethoxazole in Iran. However, ciprofloxacin, third-generation cephalosporins and carbapenems are still effective antibiotics especially against multi-drug resistant strains in Iran.

Antimicrobial and Synergistic Activity of 2,2',4-Trihydroxybenzophenone Against Bacterial Pathogens of Poultry

In poultry farming, the spread of bacterial pathogens results in disease outbreaks causing significant economic losses to this industry. Many of these pathogenic bacteria are zoonotic and have a substantial impact on public health. Antimicrobials are essential for the prevention and treatment of these bacterial infections. However, the indiscriminate use of these agents provides favorable conditions for selection, propagation and persistence of bacteria and development of antimicrobial resistance. We developed a new antimicrobial candidate that could be used alone or in synergy with research protocols for therapeutic, prophylactic and growth promoter uses in the poultry industry. The present study aimed at evaluating the antimicrobial activity of the synthetic compound 2,2′,4-trihydroxybenzophenone against pathogenic bacteria that cause important diseases in poultry and public health. We tested the hemolytic effect of this compound, studied its synergistic effect with conventional antimicrobials and analyzed the site of action on the bacteria. The results of our study showed antimicrobial activity of benzophenone against Gram-positive and Gram-negative bacteria with a similar effect in ATCC (American type culture collection) and field isolates. This compound was non-hemolytic. 2,2′,4-trihydroxybenzophenone acted on the bacterial cell wall. We identified the synergistic effect between 2,2′,4-trihydroxybenzophenone and bacitracin, this effect indicate that antimicrobial synergism may be useful for the treatment of necrotic enteritis in poultry. This compound may also be used as a growth promoter by reducing the dose of bacitracin and thus decreasing the pressure of bacterial resistance in poultry which would circumvent the development of cross-resistance in humans.

Persistence of Salmonella Typhimurium in Well Waters from a Rural Area of Changchun City, China

Salmonella-contaminated well water could cause major infection outbreaks worldwide, thus, it is crucial to understand their persistence in those waters. In this study, we investigated the persistence of Salmonella enterica serovar Typhimurium in 15 well waters from a rural area of Changchun City, China. Results illustrated that the time to reach detection limit (ttd), first decimal reduction time (δ), and the shape parameter (p) ranged from 15 to 80 days, from 5.6 to 66.9 days, and from 0.6 to 6.6, respectively. Principal component analysis showed that ttds of S. Typhimurium were positively correlated with total organic carbon, pH, NH₄⁺–N, and total phosphate. Multiple stepwise regression analysis revealed that ttds could be best predicted by NH₄⁺–N and pH. Canonical correspondence analysis and variation partition analysis revealed that NH₄⁺–N and pH, and the rest of the water parameters, could explain 27.60% and 28.15% of overall variation of the survival behavior, respectively. In addition, ttds were found to be correlated (p < 0.01) with δ and p. Our results showed that the longer survival (>2.5 months) S. Typhimurium could constitute an increased health risk to the local communities, and provided insights into the close linkage between well water quality and survival of S. Typhimurium.

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

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

Economic Assessment of Waterborne Outbreak of Cryptosporidiosis

In 2007, a waterborne outbreak of Cryptosporidium hominis infection occurred in western Ireland, resulting in 242 laboratory-confirmed cases and an uncertain number of unconfirmed cases. A boil water notice was in place for 158 days that affected 120,432 persons residing in the area, businesses, visitors, and commuters. This outbreak represented the largest outbreak of cryptosporidiosis in Ireland. The purpose of this study was to evaluate the cost of this outbreak. We adopted a societal perspective in estimating costs associated with the outbreak. Economic cost estimated was based on totaling direct and indirect costs incurred by public and private agencies. The cost of the outbreak was estimated based on 2007 figures. We estimate that the cost of the outbreak was >€19 million (≈€120,000/day of the outbreak). The US dollar equivalent based on today's exchange rates would be $22.44 million (≈$142,000/day of the outbreak). This study highlights the economic need for a safe drinking water supply.

Outbreak of unusual Salmonella enterica serovar Typhimurium monophasic variant 1,4 [5],12:i:-, Italy, June 2013 to September 2014

Monophasic variant of Salmonella enterica subspecies enterica serovar Typhimurium (monophasic S. Typhimurium), with antigenic structure 1,4,[5],12:i:-, appears to be of increasing importance in Europe. In Italy, monophasic S. Typhimurium represented the third most frequent Salmonella serovar isolated from human cases between 2004 and 2008. From June 2013 to October 2014, a total of 206 human cases of salmonellosis were identified in Abruzzo region (Central Italy). Obtained clinical isolates characterised showed S. Typhimurium 1,4,[5],12:i:- with sole resistance to nalidixic acid, which had never been observed in Italy in monophasic S. Typhimurium, neither in humans nor in animals or foods. Epidemiological, microbiological and environmental investigations were conducted to try to identify the outbreak source. Cases were interviewed using a standardised questionnaire and microbiological tests were performed on human as well as environmental samples, including samples from fruit and vegetables, pigs, and surface water. Investigation results did not identify the final vehicle of human infection, although a link between the human cases and the contamination of irrigation water channels was suggested.

Assessment of Impact and Recovery Needs in Communities Affected by the Elk River Chemical Spill, West Virginia, April 2014

OBJECTIVES

In January 2014, 4-methylcyclohexanemethanol spilled into the Elk River near Charleston, West Virginia, contaminating the water supply for about 120 000 households. The West Virginia American Water Company (WVAWC) issued a "do not use" water order for 9 counties. After the order was lifted (10 days after the spill), the communities' use of public water systems, information sources, alternative sources of water, and perceived impact of the spill on households were unclear to public health officials. To assist in recovery efforts, the West Virginia Bureau for Public Health and the Centers for Disease Control and Prevention conducted a Community Assessment for Public Health Emergency Response (CASPER).

METHODS

We used the CASPER 2-stage cluster sampling design to select a representative sample of households to interview, and we conducted interviews in 171 households in April 2014. We used a weighted cluster analysis to generate population estimates in the sampling frame.

RESULTS

Before the spill, 74.4% of households did not have a 3-day alternative water supply for each household member and pet. Although 83.6% of households obtained an alternative water source within 1 day of the "do not use" order, 37.4% of households reportedly used WVAWC water for any purpose. Nearly 3 months after the spill, 36.1% of households believed that their WVAWC water was safe, and 33.5% reported using their household water for drinking.

CONCLUSIONS

CASPER results identified the need to focus on basic public health messaging and household preparedness efforts. Recommendations included (1) encouraging households to maintain a 3-day emergency water supply, (2) identifying additional alternative sources of water for future emergencies, and (3) increasing community education to address ongoing concerns about water.

Estimated Costs of Sporadic Gastrointestinal Illness Associated with Surface Water Recreation: A Combined Analysis of Data from NEEAR and CHEERS Studies

BACKGROUND

The burden of illness can be described by addressing both incidence and illness severity attributable to water recreation. Monetized as cost, attributable disease burden estimates can be useful for environmental management decisions.

OBJECTIVES

We characterize the disease burden attributable to water recreation using data from two cohort studies using a cost of illness (COI) approach and estimate the largest drivers of the disease burden of water recreation.

METHODS

Data from the NEEAR study, which evaluated swimming and wading in marine and freshwater beaches in six U.S. states, and CHEERS, which evaluated illness after incidental-contact recreation (boating, canoeing, fishing, kayaking, and rowing) on waterways in the Chicago area, were used to estimate the cost per case of gastrointestinal illness and costs attributable to water recreation. Data on health care and medication utilization and missed days of work or leisure were collected and combined with cost data to construct measures of COI.

RESULTS

Depending on different assumptions, the cost of gastrointestinal symptoms attributable to water recreation are estimated to be $1,220 for incidental-contact recreation (range $338-$1,681) and $1,676 for swimming/wading (range $425-2,743) per 1,000 recreators. Lost productivity is a major driver of the estimated COI, accounting for up to 90% of total costs.

CONCLUSIONS

Our estimates suggest gastrointestinal illness attributed to surface water recreation at urban waterways, lakes, and coastal marine beaches is responsible for costs that should be accounted for when considering the monetary impact of efforts to improve water quality. The COI provides more information than the frequency of illness, as it takes into account disease incidence, health care utilization, and lost productivity. Use of monetized disease severity information should be included in future studies of water quality and health. Citation: DeFlorio-Barker S, Wade TJ, Jones RM, Friedman LS, Wing C, Dorevitch S. 2017. Estimated costs of sporadic gastrointestinal illness associated with surface water recreation: a combined analysis of data from NEEAR and CHEERS Studies. Environ Health Perspect 125:215-222; http://dx.doi.org/10.1289/EHP130.

A meta-analysis of public compliance to boil water advisories

Water utilities that generally provide continuous and reliable service to their customers may sometimes issue an advisory notification when service is interrupted or water quality is compromised. When the contamination is biological, utilities or the local public health agencies issue a 'boil water advisory' (BWA). The public health effectiveness of a BWA depends strongly on an implicit public understanding and compliance. In this study, a meta-analysis of 11 articles that investigated public compliance to BWA notifications was conducted. Awareness of BWA was moderately high, except in situations involving extreme weather. Reported rates of compliance were generally high, but when rate of awareness and non-compliant behavior such as brushing teeth were factored in, the median effective compliance rate was found to be around 68 percent. This does not include situations where people forgot to boil water for some part of the duration, or ingested contaminated water after the BWA was issued but before they became aware of the notification. The two-thirds compliance rate is thus an over-estimate. Results further suggest that timeliness of receipt, content of the advisory, and number of sources reporting the advisory have a significant impact on public response and compliance. This analysis points to improvements in the phrasing and content of BWA notices that could result in greater compliance, and recommends the use of a standard protocol to limit recall bias and capture the public response accurately.

A Study of Failure Events in Drinking Water Systems As a Basis for Comparison and Evaluation of the Efficacy of Potable Reuse Schemes

Potable reuse is implemented in several countries around the world to augment strained water supplies. This article presents a public health perspective on potable reuse by comparing the critical infrastructure and institutional capacity characteristics of two well-established potable reuse schemes with conventional drinking water schemes in developed nations that have experienced waterborne outbreaks. Analysis of failure events in conventional water systems between 2003 and 2013 showed that despite advances in water treatment technologies, drinking water outbreaks caused by microbial contamination were still frequent in developed countries and can be attributed to failures in infrastructure or institutional practices. Numerous institutional failures linked to ineffective treatment protocols, poor operational practices, and negligence were detected. In contrast, potable reuse schemes that use multiple barriers, online instrumentation, and operational measures were found to address the events that have resulted in waterborne outbreaks in conventional systems in the past decade. Syndromic surveillance has emerged as a tool in outbreak detection and was useful in detecting some outbreaks; increases in emergency department visits and GP consultations being the most common data source, suggesting potential for an increasing role in public health surveillance of waterborne outbreaks. These results highlight desirable characteristics of potable reuse schemes from a public health perspective with potential for guiding policy on surveillance activities.

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

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

Understanding the economic impacts of disruptions in water service

Over the past decade, there has been much attention focused on community readiness for catastrophic emergency events, such as major natural disasters or terrorist attacks. However, though the economic costs associated with experiencing such an event are high, the probability of such events occurring is quite low. At the same time, less catastrophic events that temporarily disrupt essential services to local areas, such as water and electricity, are quite common. However, there is little research that documents residents' actual economic costs when their water service is disrupted. In this paper, we contribute to the growing literature assigning economic value to residential water service by documenting the economic costs residents report from routine, small-scale water disruptions through focus groups and in-person interviews. We find that residential impacts ranged from over $1400 in savings (from working more hours than usual and eating out less than usual) to a cost of over $1000, with an overall average of $93.96. These costs, particularly when multiplied over a substantial population, become quite significant and demonstrate the importance of studying the economic costs of such events.