QMRA and water safety management: review of application in drinking water systems

Drinking water QMRA and decision-making: Sensitivity of risk to common independence assumptions about model inputs

When assessing risk posed by waterborne pathogens in drinking water, it is common to use Monte Carlo simulations in Quantitative Microbial Risk Assessment (QMRA). This method accounts for the variables that affect risk and their different values in a given system. A common underlying assumption in such analyses is that all random variables are independent (i.e., one is not associated in any way with another). Although the independence assumption simplifies the analysis, it is not always correct. For example, treatment efficiency can depend on microbial concentrations if changes in microbial concentrations either affect treatment themselves or are associated with water quality changes that affect treatment (e.g., during/after climate shocks like extreme precipitation events or wildfires). Notably, the effects of erroneous assumptions of independence in QMRA have not been widely discussed. Due to the implications of drinking water safety decisions on public health protection, it is critical that risk models accurately reflect the context being studied to meaningfully support decision-making. This work illustrates how dependence between pathogen concentration and either treatment efficiency or water consumption can impact risk estimates using hypothetical scenarios of relevance to drinking water QMRA. It is shown that the mean and variance of risk estimates can change substantially with different degrees of correlation. Data from a water supply system in Calgary, Canada are also used to illustrate the effect of dependence on risk. Recognizing the difficulty of obtaining data to empirically assess dependence, a framework to guide evaluation of the effect of dependence is presented to enhance support for decision making. This work emphasizes the importance of acknowledging and discussing assumptions implicit to models.

Water, Water Everywhere, but Every Drop Unique: Challenges in the Science to Understand the Role of Contaminants of Emerging Concern in the Management of Drinking Water Supplies

The protection and management of water resources continues to be challenged by multiple and ongoing factors such as shifts in demographic, social, economic, and public health requirements. Physical limitations placed on access to potable supplies include natural and human-caused factors such as aquifer depletion, aging infrastructure, saltwater intrusion, floods, and drought. These factors, although varying in magnitude, spatial extent, and timing, can exacerbate the potential for contaminants of concern (CECs) to be present in sources of drinking water, infrastructure, premise plumbing and associated tap water. This monograph examines how current and emerging scientific efforts and technologies increase our understanding of the range of CECs and drinking water issues facing current and future populations. It is not intended to be read in one sitting, but is instead a starting point for scientists wanting to learn more about the issues surrounding CECs. This text discusses the topical evolution CECs over time (Section 1), improvements in measuring chemical and microbial CECs, through both analysis of concentration and toxicity (Section 2) and modeling CEC exposure and fate (Section 3), forms of treatment effective at removing chemical and microbial CECs (Section 4), and potential for human health impacts from exposure to CECs (Section 5). The paper concludes with how changes to water quantity, both scarcity and surpluses, could affect water quality (Section 6). Taken together, these sections document the past 25 years of CEC research and the regulatory response to these contaminants, the current work to identify and monitor CECs and mitigate exposure, and the challenges facing the future.

Enteric pathogen reduction targets for onsite non-potable water systems: A critical evaluation

Onsite non-potable water systems (ONWS) collect and treat local source waters for non-potable end uses such as toilet flushing and irrigation. Quantitative microbial risk assessment (QMRA) has been used to set pathogen log10-reduction targets (LRTs) for ONWS to achieve the risk benchmark of 10-4 infections per person per year (ppy) in a series of two efforts completed in 2017 and 2021. In this work, we compare and synthesize the ONWS LRT efforts to inform the selection of pathogen LRTs. For onsite wastewater, greywater, and stormwater, LRTs for human enteric viruses and parasitic protozoa were within 1.5-log10 units between 2017 and 2021 efforts, despite differences in approaches used to characterize pathogens in these waters. For onsite wastewater and greywater, the 2017 effort used an epidemiology-based model to simulate pathogen concentrations contributed exclusively from onsite waste and selected Norovirus as the viral reference pathogen; the 2021 effort used municipal wastewater pathogen data and cultivable adenoviruses as the reference viral pathogen. Across source waters, the greatest differences occurred for viruses in stormwater, given the newly available municipal wastewater characterizations used for modeling sewage contributions in 2021 and the different selection of reference pathogens (Norovirus vs. adenoviruses). The roof runoff LRTs support the need for protozoa treatment, but these remain difficult to characterize due to the pathogen variability in roof runoff across space and time. The comparison highlights adaptability of the risk-based approach, allowing for updated LRTs as site specific or improved information becomes available. Future research efforts should focus on data collection of onsite water sources.

Integrating consumer risk perception and awareness with simulation-based quantitative microbial risk assessment using a coupled systems framework: A case study of private groundwater users in Ontario

Private well users in Ontario are responsible for ensuring the potability of their own private drinking water source through protective actions (i.e., water treatment, well maintenance, and regular water quality testing). In the absence of regulation and limited surveillance, quantitative microbial risk assessment (QMRA) represents the most practical and robust approach to estimating the human health burden attributable to private wells. For an increasingly accurate estimation, QMRA of private well water should be represented by a coupled model, which includes both the socio-cognitive and physical aspects of private well water contamination and microbial exposure. The objective of the current study was to determine levels of waterborne exposure via well water consumption among three sub-groups (i.e., clusters) of private well users in Ontario and quantify the risk of waterborne acute gastrointestinal illness (AGI) attributed to Giardia, shiga-toxin producing E. coli (STEC) and norovirus from private drinking water sources in Ontario. Baseline simulations were utilized to explore the effect of varying socio-cognitive scenarios on model inputs (i.e., increased awareness, protective actions, aging population). The current study uses a large spatio-temporal groundwater quality dataset and cross-sectional province-wide survey to create socio-cognitive-specific QMRA simulations to estimate the risk of waterborne AGI attributed to three enteric pathogens in private drinking waters source in Ontario. Findings suggest significant differences in the level of exposure among sub-groups of private well users. Private well users within Cluster 3 are characterised by higher levels of exposure and annual illness attributable to STEC, Giardia and norovirus than Clusters 1 and 2. Provincial incidence rates of 520.9 (1522 illness per year), 532.1 (2211 illness per year) and 605.5 (5345 illness per year) cases/100,000 private well users per year were predicted for private well users associated with Clusters 1 through 3. Established models will enable development of necessary tools tailored to specific groups of at-risk well users, allowing for preventative public health management of private groundwater sources.

Risk of Gastroenteritis from Swimming at a Wastewater-Impacted Tropical Beach Varies across Localized Scales

Population growth and changing climate are expected to increase human exposure to pathogens in tropical coastal waters. We examined microbiological water quality in three rivers within 2.3 km of each other that impact a Costa Rican beach and in the ocean outside their plumes during the rainy and dry seasons. We performed quantitative microbial risk assessment (QMRA) to predict the risk of gastroenteritis associated with swimming and the amount of pathogen reduction needed to achieve safe conditions. Recreational water quality criteria based on enterococci were exceeded in >90% of river samples but in only 13% of ocean samples. Multivariate analysis grouped microbial observations by subwatershed and season in river samples but only by subwatershed in the ocean. The modeled median risk from all pathogens in river samples was between 0.345 and 0.577, 10-fold above the U.S. Environmental Protection Agency (U.S. EPA) benchmark of 0.036 (36 illnesses/1,000 swimmers). Norovirus genogroup I (NoVGI) contributed most to risk, but adenoviruses raised risk above the threshold in the two most urban subwatersheds. The risk was greater in the dry compared to the rainy season, due largely to the greater frequency of NoVGI detection (100% versus 41%). Viral log10 reduction needed to ensure safe swimming conditions varied by subwatershed and season and was greatest in the dry season (3.8 to 4.1 dry; 2.7 to 3.2 rainy). QMRA that accounts for seasonal and local variability of water quality contributes to understanding the complex influences of hydrology, land use, and environment on human health risk in tropical coastal areas and can contribute to improved beach management. IMPORTANCE This holistic investigation of sanitary water quality at a Costa Rican beach assessed microbial source tracking (MST) marker genes, pathogens, and indicators of sewage. Such studies are still rare in tropical climates. Quantitative microbial risk assessment (QMRA) found that rivers impacting the beach consistently exceeded the U.S. EPA risk threshold for gastroenteritis of 36/1,000 swimmers. The study improves upon many QMRA studies by measuring specific pathogens, rather than relying on surrogates (indicator organisms or MST markers) or estimating pathogen concentrations from the literature. By analyzing microbial levels and estimating the risk of gastrointestinal illness in each river, we were able to discern differences in pathogen levels and human health risks even though all rivers were highly polluted by wastewater and were located less than 2.5 km from one another. This variability on a localized scale has not, to our knowledge, previously been demonstrated.

Fluence-based QMRA model for bacterial photorepair and regrowth in drinking water after decentralized UV disinfection

Ultraviolet disinfection is a promising solution for decentralized drinking water systems such as communal water taps. A potential health risk is enzymatic photorepair of pathogens after UV disinfection, which can result in regrowth of pathogens. Even though photorepair is a known issue, no formal risk assessments have been conducted for photorepair after UV disinfection in drinking water. The main objective was to construct a quantitative microbial risk assessment (QMRA) of photorepair after UV disinfection of drinking water in a decentralized system. UV disinfection and photorepair kinetics for E. coli were modelled using reproducible fluence-based determinations. Impacts of water collection patterns, and wavelength-dependent water container material transmittance, sunlight intensity, and photorepair enzyme absorbance were quantified. After UV disinfection by 16 or 40 mJ/cm² of < 5-log microorganisms per L, risk of infection did not exceed 1-in-10,000 under conditions permitting E. coli photorepair. Risk from photorepair was less than 1-in-10,000 for photorepair light exposure < 0.75 h throughout the day for UV fluence 16 mJ/cm² or greater. UV disinfection followed by solar disinfection surpassing photoreactivation during storage reduced risk below 1-in-10,000 for photorepair light exposure > 2.5 h between modelled times of 9 AM - 3 PM. The model can be expanded to other pathogens as UV fluence and photorepair fluence response kinetics become available, and this QMRA can be used to inform the placement of community water access points to reduce risk of photorepair and ensure adequate shelf life of UV disinfected water under safe storage conditions.

Assessing the risk of acute gastrointestinal illness attributable to three enteric pathogens from contaminated private water wells in Ontario

The province of Ontario compromises the largest groundwater reliant population in Canada serving approximately 1.6 million individuals. Unlike municipal water systems, private well water is not required to meet water quality regulatory standards and thus source maintenance, treatment and testing remains the responsibility of the well owner. Infections associated with private drinking water systems are rarely documented given their typically sporadic nature, thus the human health effects (e.g., acute gastrointestinal illness (AGI)) on consumers remains relatively unknown, representing a significant gap in water safety management. The current study sought to quantify the risk of waterborne AGI attributed to Giardia, shiga-toxin producing E. coli (STEC) and norovirus from private drinking water sources in Ontario using Monte Carlo simulation-based quantitative microbial risk assessment (QMRA). Findings suggest that consumption of contaminated private well water in Ontario is responsible for approximately 4823 AGI cases annually, with 3464 (71.8%) and 1359 (28.1%) AGI cases predicted to occur in consolidated and unconsolidated aquifers, respectively. By pathogen, waterborne AGI was attributed to norovirus (62%; 2991/4823), Giardia (24.6%; 1186/4823) and STEC (13.4%; 646/4823). The developed QMRA framework was used to assess the potential health impacts of partial and total well water treatment system failure. In the unlikely event of total treatment failure, total mean annual illnesses are predicted to almost double (4217 to 7064 cases per year), highlighting the importance of effective water treatment and comprehensive testing programs in reducing infectious health risks attributable to private well water in Ontario. Study findings indicate significant underreporting of waterborne AGI rates at the provincial level likely biasing public health interventions and programs that are effective in monitoring and minimizing the health risk associated with private well water.

Photocatalytic Inactivation of Co-Culture of E. coli and S. epidermidis Using APTES-Modified TiO2

The presented work shows the antibacterial activity of TiO₂ photocatalysts modified by 3-aminopropyltriethoxysilane (APTES). The APTES-functionalized TiO₂ samples were obtained by the solvothermal process followed by calcination. The antibacterial activity of APTES/TiO₂ samples was evaluated with two species of bacteria, Escherichia coli and Staphylococcus epidermidis, under artificial solar light (ASL) irradiation. The used bacteria are model organisms characterized by negative zeta potential (approx. -44.2 mV for E. coli and -42.3 mV for S. epidermidis). For the first time, the antibacterial properties of APTES-functionalized TiO₂ were evaluated against mono- and co-cultured bacteria. The high antibacterial properties characterized the obtained APTES-modified nanomaterials. The best antibacterial properties were presented in the TiO₂-4 h-120 °C-300 mM-Ar-300 °C sample (modified with 300 mM of APTES and calcined at 300 °C). The improvement of the antibacterial properties was attributed to a positive value of zeta potential, high surface area, and porous volume.

Risk-based treatment targets for onsite non-potable water systems using new pathogen data

Using local sources (roof runoff, stormwater, graywater, and onsite wastewater) to meet non-potable water demands can minimize potable water use in buildings and increase supply reliability. In 2017, an Independent Advisory Panel developed a risk-based framework to identify pathogen log reduction targets (LRTs) for onsite non-potable water systems (ONWSs). Subsequently, California's legislature mandated the development and adoption of regulations-including risk-based LRTs-for use in multifamily residential, commercial, and mixed-use buildings. A California Expert Panel was convened in 2021 to (1) update the LRT requirements using new, quantitative pathogen data and (2) propose treatment trains capable of meeting the updated LRTs. This paper presents the updated risk-based LRTs for multiple pathogens (viruses, protozoa, and bacteria) and an expanded set of end-uses including toilet flushing, clothes washing, irrigation, dust and fire suppression, car washing, and decorative fountains. The updated 95th percentile LRTs required for each source water, pathogen, and end-use were typically within 1-log₁₀ of the 2017 LRTs regardless of the approach used to estimate pathogen concentrations. LRT requirements decreased with influent pathogen concentrations from wastewater to graywater to stormwater to roof runoff. Cost and footprint estimates provide details on the capital, operations and maintenance, and siting requirements for ONWS implementation.

Cross-connections in drinking water distribution networks: Quantitative microbial risk assessment in combination with fault tree analysis and hydraulic modelling

Deficiencies in drinking water distribution networks, such as cross-connections, may lead to contamination of the drinking water and pose a serious health risk to consumers. Cross-connections and backflows are considered among the most severe public health risks in distribution networks. The aim of this paper was to provide a framework for estimating the risk of infection from cross-connection and backflow events. Campylobacter, norovirus, and Cryptosporidium were chosen as reference pathogens for this study. The theoretical framework was constructed based on the fault tree analysis methodology. National aggregated cross-connection incident data was used to calculate the probability of a contamination event occurring in Swedish networks. Three risk cases were evaluated: endemic, elevated, and extreme. Quantitative microbial risk assessment (QMRA) was used to assess daily risk of infection for average national estimates. The framework was also evaluated using local data from the Gothenburg network. The daily risk of infection from cross-connection and backflow events in Swedish networks was generally above an acceptable target level of 10^-6 for all reference pathogens and modelled cases; the exception was for the Gothenburg system where the risk was lower than 10^-7. An outbreak case study was used to validate the framework results. For the outbreak case study, contaminant transport in the network was simulated using hydraulic modelling (EPANET), and risk estimates were calculated using QMRA. The outbreak simulation predicted between 97 and 148 symptomatic infections, while the epidemiological survey conducted during the outbreak reported 179 cases of illness. The fault tree analysis framework was successfully validated using an outbreak case study, though it was shown on the example of Gothenburg that local data is still needed for well-performing systems. The framework can help inform microbial risk assessments for drinking water suppliers, especially ones with limited resources and expertise in this area.

An assessment of the health risks associated with shared sanitation: a case study of the community ablution blocks in Durban, South Africa

Shared sanitation facilities have been hailed as an innovative approach to solve the challenge with sanitation access. However, these facilities may act as hotspots for disease transmission due to unhygienic conditions. In this study we used quantitative (based on Escherichia coli contamination) techniques to assess the health risks associated with the use of community ablution blocks (CABs). The most contaminated surfaces were the cistern handle (5.7 Log₁₀ cfu/cm²) and internal pull latch (5.8 Log₁₀ cfu/cm²). Based on the E. coli contamination, at least two people out of 100 CAB users might be potentially infected when they touch "hot" surfaces. These risks were modelled assuming transfer of potentially pathogenic E. coli from these surfaces to the mouth. The incorporation of risk-reduction measures, such as wiping of these surfaces or washing of hands, could potentially result in significant reduction of infection risks. The most significant risk-reduction intervention was determined to be wiping of the contact surfaces, especially twice prior to contact. A combination of risk-reduction interventions could further reduce the risks. This study shows that contamination of contact surfaces within shared CABs could lead to increased risks of infections, requiring measures aimed at reducing the associated risks. The risk assessment framework used in this study could therefore be applied in similar settings to estimate associated health risks with the use of such facilities.

A scientometric study on quantitative microbial risk assessment in water quality analysis across 6 years (2016-2021)

Water contamination by microbes is a growing environmental challenge that has exacerbated the apparent scarcity of safe drinking water. To alleviate this challenge, it is important to screen water for pathogens to reduce the risk of contracting waterborne diseases among consumers. The use of the quantitative microbial risk assessment (QMRA) tool to approximate illness possibility from exposure to microorganisms using dose-response models between pathogens and their associated health impacts is, therefore, recommended. The aim of this study was to explore the use of QMRA in water quality assessment using a scientometric approach and data sourced from the Web of Science (WoS) database for the period between 2016 and 2021. Articles were searched in the WoS databases before downloading the content for a bibliometric analysis using the VOSviewer software. Additionally, Microsoft Excel was used to analyze the inter-relationships of the searched results. Journal articles had the highest results from the searched query at 90.6% compared to other forms of output. High-impact journals such as the Science of the Total Environment and Water Research had the highest number of publications at 11.056 and 7.5%, respectively. Keyword analysis showed the multidisciplinary nature of the search query based on the clustered themes. The USA and China showed greater publication output with a total of 51.7% of total publications compared to developing countries due to their high research potential and extensive collaborative networks. A similar trend was evident in the institutional analysis with the University of California, USA, and the Chinese Academy of Sciences being the highest research contributors with 8% of the searched output. The study highlighted the need to extend research inputs to developing countries of Africa and Asia to improve their research and development capacity, productivity and share knowledge on QMRA in water quality assessment.

A Global Overview of SARS-CoV-2 in Wastewater: Detection, Treatment, and Prevention

A novel coronavirus (SARS-CoV-2) causing corona virus disease 2019 (COVID-19) has attracted global attention due to its highly infectious and pathogenic properties. Most of current studies focus on aerosols released from infected individuals, but the presence of SARS-CoV-2 in wastewater also should be examined. In this review, we used bibliometrics to statistically evaluate the importance of water-related issues in the context of COVID-19. The results show that the levels and transmission possibilities of SARS-CoV-2 in wastewater are the main concerns, followed by potential secondary pollution by the intensive use of disinfectants, sludge disposal, and the personal safety of workers. The presence of SARS-CoV-2 in wastewater requires more attention during the COVID-19 pandemic. Thus, the most effective techniques, i.e., wastewater-based epidemiology and quantitative microbial risk assessment, for virus surveillance in wastewater are systematically analyzed. We further explicitly review and analyze the successful operation of a sewage treatment plant in Huoshenshan Hospital in China as an example and reference for other sewage treatment systems to properly ensure discharge safety and tackle the COVID-19 pandemic. This review offers deeper insight into the prevention and control of SARS-CoV-2 and similar viruses in the post-COVID-19 era from a wastewater perspective.

Quantitative microbiological risk assessment of complex microbial community in Prawn farm wastewater and applicability of nanoparticles and probiotics for eliminating of antibiotic-resistant bacteria

The current review highlighted the quantitative microbiological risk assessment of Vibrio parahaemolyticus in Prawn farm wastewaters (PFWWs) and the applicability of nanoparticles for eliminating antibiotic-resistant bacteria (ARB). The high availability of the antibiotics in the environment and their transmission into human through the food-chain might cause unknown health effects. The aquaculture environments are considered as a reservoir for the antibiotic resistance genes (ARGs) and contributed effectively in the increasing of ABR. The metagenomic analysis is used to explore ARGs in the non-clinical environment. V. parahaemolyticus is among the pathogenic bacteria which are transmitted through sea food causing human acute gastroenteritis due to available thermostable direct hemolysin (tdh), adhesins, TDH related hemolysin (trh). The inactivation of pathogenic bacteria using nanoparticles act by disturbing the cell membrane, interrupting the transport system, DNA and mitochondria damage, and oxidizing the cellular component by reactive oxygen species (ROS). The chloramphenicol, nitrofurans, and nitroimidazole are among the prohibited drugs in fish and fishery product. The utilization of probiotics is the most effective and safe alternative for antibiotics in Prawn aquaculture. This review will ensure public understanding among the readers on how they can decrease the risk of the antimicrobial resistance distribution in the environment.

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

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

Using surrogate data to assess risks associated with microbial peak events in source water at drinking water treatment plants

A monitoring strategy was implemented at two drinking water treatment plants in Quebec, Canada, to evaluate microbial reduction performances of full-scale treatment processes under different source water conditions. β-D-glucuronidase activity in source water was automatically monitored in near-real-time to establish baseline and event conditions at each location. High-volume water samples (50-1,500 L) were collected at the inflow and the outflow of coagulation/flocculation, filtration, and UV disinfection processes and were analysed for two naturally occurring surrogate organisms: Escherichia coli and Clostridium perfringens. Source water Cryptosporidium data and full-scale C. perfringens reduction data were entered into a quantitative microbial risk assessment (QMRA) model to estimate daily infection risks associated with exposures to Cryptosporidium via consumption of treated drinking water. Daily mean E. coli and Cryptosporidium concentrations in source water under event conditions were in the top 5% (agricultural site) or in the top 15% (urban site) of what occurs through the year at these drinking water treatment plants. Reduction performances of up to 6.0-log for E. coli and 5.6-log for C. perfringens were measured by concentrating high-volume water samples throughout the treatment train. For both drinking water treatment plants, removal performances by coagulation/flocculation/sedimentation processes were at the high end of the range of those reported in the literature for bacteria and bacterial spores. Reductions of E. coli and C. perfringens by floc blanket clarification, ballasted clarification and rapid sand filtration did not deteriorate during two snowmelt/rainfall events. QMRA results suggested that daily infection risks were similar during two rainfall/snowmelt events than during baseline conditions. Additional studies investigating full-scale reductions would be desirable to improve the evaluation of differences in treatment performances under various source water conditions.

Detection of SARS-CoV-2 RNA on contact surfaces within shared sanitation facilities

Contamination of contact surfaces with SARS-CoV-2 has been reported as a potential route for the transmission of COVID-19. This could be a major issue in developing countries where access to basic sanitation is poor, leading to the sharing of toilet facilities. In this study, we report SARS-CoV-2 contamination of key contact surfaces in shared toilets and the probabilistic risks of COVID-19 infections based on detection and quantification of the nucleic acid on the surfaces. We observed that 54-69% of the contact surfaces were contaminated, with SARS-CoV-2 loads ranging from 28.1 to 132.7 gene copies per cm². Toilet seats had the highest contamination, which could be attributed to shedding of the virus in feces and urine. We observed a significant reduction in viral loads on the contaminated surfaces after cleaning, showing the potential of effective cleaning on the reduction of contamination. The pattern of contamination indicates that the most contaminated surfaces are those that are either commonly touched by users of the shared toilets or easily contaminated with feces and urine. These surfaces were the toilet seats, cistern handles and tap handles. The likelihood (probability) of infection with COVID-19 on these surfaces was highest on the toilet seat (1.76 × 10^-4(1.58 × 10^-6)) for one time use of the toilet. These findings highlight the potential risks for COVID-19 infections in the event that intact infectious viral particles are deposited on these contact surfaces. Therefore, this study shows that shared toilet facilities in densely populated areas could lead to an increase in risks of COVID-19 infections. This calls for the implementation of risk reduction measures, such as regular washing of hands with soap, strict adherence to wearing face masks, and effective and regular cleaning of shared facilities.

Navigating Data Uncertainty and Modeling Assumptions in Quantitative Microbial Risk Assessment in an Informal Settlement in Kampala, Uganda

Decision-makers in developing communities often lack credible data to inform decisions related to water, sanitation, and hygiene. Quantitative microbial risk assessment (QMRA), which quantifies pathogen-related health risks across exposure routes, can be informative; however, the utility of QMRA for decision-making is often undermined by data gaps. This work integrates QMRA, uncertainty and sensitivity analyses, and household surveys in Bwaise, Kampala (Uganda) to characterize the implications of censored data management, identify sources of uncertainty, and incorporate risk perceptions to improve the suitability of QMRA for informal settlements or similar settings. In Bwaise, drinking water, hand rinse, and soil samples were collected from 45 households and supplemented with data from 844 surveys. Quantified pathogen (adenovirus, Campylobacter jejuni, and Shigella spp./EIEC) concentrations were used with QMRA to model infection risks from exposure through drinking water, hand-to-mouth contact, and soil ingestion. Health risks were most sensitive to pathogen data, hand-to-mouth contact frequency, and dose-response models (particularly C. jejuni). When managing censored data, results from upper limits of detection, half of limits of detection, and uniform distributions returned similar results, which deviated from lower limits of detection and maximum likelihood estimation imputation approaches. Finally, risk perceptions (e.g., it is unsafe to drink directly from a water source) were identified to inform risk management.

Evaluation of pathogen risks using QMRA to explore wastewater reuse options: A case study from New Delhi in India

Selecting appropriate reuse for treated wastewater is a challenge. The current investigation outlines the utilization of quantitative microbial risk assessment (QMRA) to assist Effluent Treatment Plant (ETP) management to determine the best-possible reuse of treated wastewater from 11 ETPs in Delhi. Four representative pathogens: pathogenic Escherichia coli spp., Salmonella spp., Cryptosporidium spp. and Giardia spp. were selected to characterize microbial water quality. Reuse options selected based on the survey and interaction with ETP managers include crop irrigation, garden irrigation, toilet flush and industrial applications. The probability of infection was characterized for two exposure groups: workers and children. Water quality monitoring indicates the occurrence of pathogenic E. coli spp. (100%), Salmonella spp. (63%), Cryptosporidium spp. (81%) and Giardia spp. (45%) in the treated wastewater. QMRA reveals the annual median-probability of infection above acceptable limits for pathogenic E. coli spp., Cryptosporidium spp. and Salmonella spp. The probabilities of Giardia-associated infections were low. Adults showed a 1.24 times higher probability of infection compared to children. Sensitivity analysis indicated pathogen concentration as the most critical factor. The study highlights that the existing plans for chlorination-based treatment technology may prove insufficient in reducing the risk for selected reuse options; but, alternate on-site control measures and up-grading water reuse protocol may be effective.

Quantitative microbial risk assessment of SARS-CoV-2 for workers in wastewater treatment plants

Faecal-oral transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is yet to be validated, but it is a critical issue and additional research is needed to elucidate the risks of the novel coronavirus in sanitation systems. This is the first study that investigates the potential health risks of SARS-CoV-2 in sewage to wastewater treatment plant (WWTP) workers. A quantitative microbial risk assessment (QMRA) is applied for three COVID-19 scenarios (moderate, aggressive and extreme) to study the effects of different stages of the pandemic in terms of percentage of infected population on the probability of infection to WWTP workers. A dose-response model for SARS-CoV-1 (as a surrogate pathogen) is assumed in the QMRA for SARS-CoV-2 using an exponential model with k = 4.1 × 10². Literature data are incorporated to inform assumptions for calculating the viral load, develop the model, and derive a tolerable infection risk. Results reveal that estimates of viral RNA in sewage at the entrance of WWTPs ranged from 4.14 × 10¹ to 5.23 × 10³ GC·mL^-1 (viable virus concentration from 0.04 to 5.23 PFU·mL^-1, respectively). In addition, estimated risks for the aggressive and extreme scenarios (2.6 × 10^-3 and 1.3 × 10^-2, respectively) were likely to be above the derived tolerable infection risk for SARS-CoV-2 of 5.5 × 10^-4 pppy, thus reinforcing the concern of sewage systems as a possible transmission pathway of SARS-CoV-2. These findings are helpful as an early health warning tool and in prioritizing upcoming risk management strategies, such as Emergency Response Plans (ERPs) for water and sanitation operators during the COVID-19 and future pandemics.

Quantitative microbial risk assessment of SARS-CoV-2 for workers in wastewater treatment plants

Faecal-oral transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is yet to be validated, but it is a critical issue and additional research is needed to elucidate the risks of the novel coronavirus in sanitation systems. This is the first study that investigates the potential health risks of SARS-CoV-2 in sewage to wastewater treatment plant (WWTP) workers. A quantitative microbial risk assessment (QMRA) is applied for three COVID-19 scenarios (moderate, aggressive and extreme) to study the effects of different stages of the pandemic in terms of percentage of infected population on the probability of infection to WWTP workers. A dose-response model for SARS-CoV-1 (as a surrogate pathogen) is assumed in the QMRA for SARS-CoV-2 using an exponential model with k = 4.1 × 10². Literature data are incorporated to inform assumptions for calculating the viral load, develop the model, and derive a tolerable infection risk. Results reveal that estimates of viral RNA in sewage at the entrance of WWTPs ranged from 4.14 × 10¹ to 5.23 × 10³ GC·mL^-1 (viable virus concentration from 0.04 to 5.23 PFU·mL^-1, respectively). In addition, estimated risks for the aggressive and extreme scenarios (2.6 × 10^-3 and 1.3 × 10^-2, respectively) were likely to be above the derived tolerable infection risk for SARS-CoV-2 of 5.5 × 10^-4 pppy, thus reinforcing the concern of sewage systems as a possible transmission pathway of SARS-CoV-2. These findings are helpful as an early health warning tool and in prioritizing upcoming risk management strategies, such as Emergency Response Plans (ERPs) for water and sanitation operators during the COVID-19 and future pandemics.

The role of biofilm in the development and dissemination of ubiquitous pathogens in drinking water distribution systems: an overview of surveillance, outbreaks, and prevention

A variety of pathogenic microorganisms can survive in the drinking water distribution systems (DWDS) by forming stable biofilms and, thus, continually disseminating their population through the system's dynamic water bodies. The ingestion of the pathogen-contaminated water could trigger a broad spectrum of illnesses and well-being-related obstacles. These waterborne diseases are a significant concern for babies, pregnant women, and significantly low-immune individuals. This review highlights the recent advances in understanding the microbiological aspects of drinking water quality, biofilm formation and its dynamics, health issues caused by the emerging microbes in biofilm, and approaches for biofilm investigation its prevention and suppression in DWDS.

Quantitation of Risk Reduction of E. coli Transmission After Using Antimicrobial Hand Soap

Handwashing with soap is an effective and economical means to reduce the likelihood of Escherichia coli infection from indirect contact with contaminated surfaces during food preparation. The purpose of this study was to conduct a quantitative microbial risk assessment (QMRA) to evaluate the risk of infection from indirect contact with fomites contaminated with E. coli after hand washing with antimicrobial hand soaps. A Monte Carlo simulation was done with a total of 10,000 simulations to compare the effectiveness of two antimicrobial and one control (non-antimicrobial) bar soaps in reducing the exposure and infection risk compared to no hand washing. The numbers of E. coli on several fomites commonly found in household kitchens, as well as the transfer rates between fomites and onto fingertips, were collected from the literature and experimental data. The sponsor company provided the E. coli survival on hands after washing with antimicrobial and control soaps. A number of scenarios were evaluated at two different exposure doses (high and low). Exposure scenarios included transfer of E. coli between meat-to-cutting board surface-to-hands, meat-to-knife surface-to-hands, and from a countertop surface-to-hands, kitchen sponge-to-hands, hand towel-to-hands, and dishcloth-to-hands. Results showed that the risks of illness after washing with the control soap was reduced approximately 5-fold compared to no handwashing. Washing with antimicrobial soap reduced the risk of E. coli infection by an average of about 40-fold compared with no handwashing. The antimicrobial soaps ranged from 3 to 32 times more effective than the non-antimicrobial soap, depending on the specific exposure scenario. Importance: The Centers for Disease Control and Prevention indicate the yearly incidence rate of Shiga Toxin producing E. coli infections is about 1.7/100,000, with about 10% of cases leading to life-threatening hemolytic uremic syndrome and 3–5% leading to death. Our findings confirm handwashing with soap reduces the risks associated with indirect transmission of E. coli infection from contact with fomites during food preparation. Further, in these exposure scenarios, antimicrobial soaps were more effective overall than the non-antimicrobial soap in reducing exposure to E. coli and risk of infection.

Review of Modeling Methodologies for Managing Water Distribution Security

Water distribution systems are vulnerable to hazards that threaten water delivery, water quality, and physical and cybernetic infrastructure. Water utilities and managers are responsible for assessing and preparing for these hazards, and researchers have developed a range of computational frameworks to explore and identify strategies for what-if scenarios. This manuscript conducts a review of the literature to report on the state of the art in modeling methodologies that have been developed to support the security of water distribution systems. First, the major activities outlined in the emergency management framework are reviewed; the activities include risk assessment, mitigation, emergency preparedness, response, and recovery. Simulation approaches and prototype software tools are reviewed that have been developed by government agencies and researchers for assessing and mitigating four threat modes, including contamination events, physical destruction, interconnected infrastructure cascading failures, and cybernetic attacks. Modeling tools are mapped to emergency management activities, and an analysis of the research is conducted to group studies based on methodologies that are used and developed to support emergency management activities. Recommendations are made for research needs that will contribute to the enhancement of the security of water distribution systems.

Implementation of quantitative microbial risk assessment (QMRA) for public drinking water supplies: Systematic review

In the more than 15 years since its introduction, quantitative microbial risk assessment (QMRA) has become a widely used technique for assessing population health risk posed by waterborne pathogens. However, the variation in approaches taken for QMRA in relation to drinking water supply is not well understood. This systematic review identifies, categorises, and critically synthesises peer-reviewed and academic case studies of QMRA implementation for existing distributed public drinking water supplies. Thirty-nine English-language, peer-reviewed and academic studies published from 2003 to 2019 were identified. Key findings were synthesised in narrative form. The overall designs of the included studies varied widely, as did the assumptions used in risk calculation, especially in relation to pathogen dose. There was also substantial variation in the degree to which the use of location-specific data weighed with the use of assumptions when performing risk calculation. In general, the included studies' complexity did not appear to be associated with greater result certainty. Factors relating to pathogen dose were commonly influential on risk estimates whereas dose-response parameters tended to be of low relative influence. In two of the included studies, use of the 'susceptible fraction' factor was inconsistent with recognised guidance and potentially led to the underestimation of risk. While approaches and assumptions used in QMRA need not be standardised, improvement in the reporting of QMRA results and uncertainties would be beneficial. It is recommended that future authors consider the water supply QMRA reporting checklist developed for the current review. Consideration of the broad types of uncertainty relevant to QMRA is also recommended. Policy-makers should consider emergent discussion on acute microbial health-based targets when setting normative guidelines. The continued representation of QMRA case studies within peer-reviewed and academic literature would also enhance future implementation. Further research is needed on the optimisation of QMRA resourcing given the application context.

Synergy between quantitative microbial source tracking (qMST) and quantitative microbial risk assessment (QMRA): A review and prospectus

The use of microbial source tracking (MST) marker genes has grown in recent years due to the need to attribute point and non-point fecal contamination to specific sources. Quantitative microbial risk assessment (QMRA) is a modeling approach used to estimate health risks from exposure to feces-contaminated water and associated pathogens. A combination of these approaches [quantitative MST (qMST) and QMRA] can provide additional pathogen-related information for prioritizing and addressing health risks, compared to reliance on conventional fecal indicator bacteria (FIB). To inform expansion of this approach, a review of published qMST-QMRA studies was conducted to summarize the state of the science and to identify research needs. The reviewed studies primarily aimed to identify what levels of MST marker genes in hypothetical recreational waterbodies would exceed the United States Environmental Protection Agency (USEPA) risk benchmarks for primary contact recreators. The QMRA models calculated relationships between MST marker gene(s) and reference pathogens based on published data in the literature. The development of a robust, accurate relationship was identified as an urgent research gap for qMST-QMRA. This metric requires additional knowledge to quantify the relationship between MST marker genes and the degree of variability in decay of pathogens as a dynamic function of environmental conditions and combinations of fecal sources at multiple spatial and temporal scales. Improved characterization of host shedding rates of host-associated microorganisms (i.e., MST marker genes), as well as fate and transport of these microorganisms and their nucleic acids, would facilitate expansion of this approach to other exposure pathways. Incorporation of information regarding the recovery efficiency, and host-specificity of MST marker genes into QMRA model parameters, and the sensitivity analysis, would greatly improve risk management and site-specific water monitoring criteria.

Capsid Integrity qPCR—An Azo-Dye Based and Culture-Independent Approach to Estimate Adenovirus Infectivity after Disinfection and in the Aquatic Environment

Recreational, reclaimed and drinking source waters worldwide are under increasing anthropogenic pressure, and often contain waterborne enteric bacterial, protozoan, and viral pathogens originating from non-point source fecal contamination. Recently, the capsid integrity (ci)-qPCR, utilizing the azo-dyes propidium monoazide (PMA) or ethidium monoazide (EMA), has been shown to reduce false-positive signals under laboratory conditions as well as in food safety applications, thus improving the qPCR estimation of virions of public health significance. The compatibility of two widely used human adenovirus (HAdV) qPCR protocols was evaluated with the addition of a PMA/EMA pretreatment using a range of spiked and environmental samples. Stock suspensions of HAdV were inactivated using heat, UV, and chlorine before being quantified by cell culture, qPCR, and ci-qPCR. Apparent inactivation of virions was detected for heat and chlorine treated HAdV while there was no significant difference between ci-qPCR and qPCR protocols after disinfection by UV. In a follow-up comparative analysis under more complex matrix conditions, 51 surface and 24 wastewater samples pre/post UV treatment were assessed for enteric waterborne HAdV to evaluate the ability of ci-qPCR to reduce the number of false-positive results when compared to conventional qPCR and cell culture. Azo-dye pretreatment of non-UV inactivated samples was shown to improve the ability of molecular HAdV quantification by reducing signals from virions with an accessible genome, thereby increasing the relevance of qPCR results for public health purposes, particularly suited to resource-limited low and middle-income settings.

Role of filtration in managing the risk from Cryptosporidium in commercial swimming pools - a review

Most commercial swimming pools use pressurised filters, typically containing sand media, to remove suspended solids as part of the water treatment process designed to keep water attractive, clean and safe. The accidental release of faecal material by bathers presents a poorly quantified risk to the safety of swimmers using the pool. The water treatment process usually includes a combination of maintaining a residual concentration of an appropriate biocide in the pool together with filtration to physically remove particles, including microbial pathogens, from the water. However, there is uncertainty about the effectiveness of treatment processes in removing all pathogens, and there has been growing concern about the number of reported outbreaks of the gastrointestinal disease cryptosporidiosis, caused by the chlorine-resistant protozoan parasite Cryptosporidium. A number of interacting issues influence the effectiveness of filtration for the removal of Cryptosporidium oocysts from swimming pools. This review explains the mechanisms by which filters remove particles of different sizes (including oocyst-sized particles, typically 4-6 μm), factors that affect the efficiency of particle removal (such as filtration velocity), current recommended management practices, and identifies further work to support the development of a risk-based management approach for the management of waterborne disease outbreaks from swimming pools.

Spatio-temporal dynamics of virus and bacteria removal in dual-media contact-filtration for drinking water

Microorganism removal efficiencies in deep bed filters vary with time and depth in the filter bed as the filter collects particles. Improved knowledge of such dynamics is relevant for the design, operation and microbial risk assessment of filtration processes for drinking water treatment. Here we report on a high-resolution spatio-temporal characterization of virus and bacteria removal in a pilot-scale dual-media filter, operated in contact-filtration mode. Microorganisms investigated were bacteriophage Salmonella typhimurium 28B (plaque assay, n=154)), fRNA phage MS2 (plaque assay/RT-qPCR, n=87) and E. coli (Colilert-18, n=73). Microscopic and macroscopic filtration models were used to investigate and characterize the removal dynamics. Results show that ripening/breakthrough fronts for turbidity, viruses and E. coli migrated in a wave-like manner across the depth of the filter. Virus removal improved continuously throughout the filter cycle and viruses broke through almost simultaneously with turbidity. Ripening for E. coli took longer than ripening for turbidity, but the bacteria broke through before turbidity breakthrough. Instantaneous log-removal peaked at 3.2, 3.0 and 4.5 for 28B, MS2 and E. coli, respectively. However, true average log-removal during the period of stable effluent turbidity was significantly lower at 2.5, 2.3 and 3.6, respectively. Peak observed filter coefficients λ were higher than predicted by ideal filtration theory. This study demonstrates the importance of carefully designed sampling regimes when characterizing microorganism removal efficiencies of deep bed filters.

Selecting Household Water Treatment Options on the Basis of World Health Organization Performance Testing Protocols

The World Health Organization's International Scheme to Evaluate Household Water Treatment Technologies serves to benchmark microbiological performance of existing and novel technologies and processes for small-scale drinking water treatment according to a tiered system. There is widespread uncertainty around which tiers of performance are most appropriate for technology selection and recommendation in humanitarian response or for routine safe water programming. We used quantitative microbial risk assessment (QMRA) to evaluate attributable reductions in diarrheal disease burden associated with water treatment technologies meeting the three tiers of performance under this Scheme, across a range of conditions. According to mean estimates and under most modeling conditions, potential health gains attributable to microbiologically improved drinking water are realized at the middle tier of performance: "comprehensive protection: high pathogen removal (★★)" for each reference pathogen. The highest tier of performance may yield additional marginal health gains where untreated water is especially contaminated and where adherence is 100%. Our results highlight that health gains from improved efficacy of household water treatment technology remain marginal when adherence is less than 90%. While selection of water treatment technologies that meet minimum WHO efficacy recommendations for comprehensive protection against waterborne pathogens is critical, additional criteria for technology choice and recommendation should focus on potential for correct, consistent, and sustained use.

Faster and safer: Research priorities in water and health

The United Nations' Sustainable Development Goals initiated in 2016 reiterated the need for safe water and healthy lives across the globe. The tenth anniversary meeting of the International Water and Health Seminar in 2018 brought together experts, students, and practitioners, setting the stage for development of an inclusive and evidence-based research agenda on water and health. Data collection relied on a nominal group technique gathering perceived research priorities as well as underlying drivers and adaptation needs. Under a common driver of public health protection, primary research priorities included the socioeconomy of water, risk assessment and management, and improved monitoring methods and intelligence. Adaptations stemming from these drivers included translating existing knowledge to providing safe and timely services to support the diversity of human water needs. Our findings present a comprehensive agenda of topics at the forefront of water and health research. This information can frame and inform collective efforts of water and health researchers over the coming decades, contributing to improved water services, public health, and socioeconomic outcomes.

Quantitative risk assessment of norovirus and adenovirus for the use of reclaimed water to irrigate lettuce in Catalonia

Wastewater is an important resource in water-scarce regions of the world, and its use in agriculture requires the guarantee of acceptable public health risks. The use of fecal indicator bacteria to evaluate safety does not represent viruses, the main potential health hazards. Viral pathogens could complement the use of fecal indicator bacteria in the evaluation of water quality. In this study, we characterized the concentration and removal of human adenovirus (HAdV) and norovirus genogroup II (NoV GII), highly abundant and important viral pathogens found in wastewater, in two wastewater treatment plants (WWTPs) that use different tertiary treatments (constructed wetland vs conventional UV, chlorination and Actiflo® treatments) for a year in Catalonia. The main objective of this study was to develop a Quantitative Microbial Risk Assessment for viral gastroenteritis caused by norovirus GII and adenovirus, associated with the ingestion of lettuce irrigated with tertiary effluents from these WWTPs. The results show that the disease burden of NoV GII and HAdV for the consumption of lettuce irrigated with tertiary effluent from either WWTP was higher than the WHO recommendation of 10-6 DALYs for both viruses. The WWTP with constructed wetland showed a higher viral reduction on average (3.9 and 2.8 logs for NoV GII and HAdV, respectively) than conventional treatment (1.9 and 2.5 logs) but a higher variability than the conventional WWTP. Sensitivity analysis demonstrated that the input parameters used to estimate the viral reduction by treatment and viral concentrations accounted for much of the model output variability. The estimated reductions required to reach the WHO recommended levels in tertiary effluent are influenced by the characteristics of the treatments developed in the WWTPs, and additional average reductions are necessary (in WWTP with a constructed wetland: A total of 6.7 and 5.1 logs for NoV GII and HAdV, respectively; and in the more conventional treatment: 7 and 5.6 logs). This recommendation would be achieved with an average quantification of 0.5 genome copies per 100 mL in reclaimed water for both viruses. The results suggest that the analyzed reclaimed water would require additional treatments to achieve acceptable risk in the irrigation of vegetables with reclaimed water.

Validation of Quantitative Microbial Risk Assessment Using Epidemiological Data from Outbreaks of Waterborne Gastrointestinal Disease

The assumptions underlying quantitative microbial risk assessment (QMRA) are simple and biologically plausible, but QMRA predictions have never been validated for many pathogens. The objective of this study was to validate QMRA predictions against epidemiological measurements from outbreaks of waterborne gastrointestinal disease. I screened 2,000 papers and identified 12 outbreaks with the necessary data: disease rates measured using epidemiological methods and pathogen concentrations measured in the source water. Eight of the 12 outbreaks were caused by Cryptosporidium, three by Giardia, and one by norovirus. Disease rates varied from 5.5 × 10^-6 to 1.1 × 10^-2 cases/person-day, and reported pathogen concentrations varied from 1.2 × 10^-4 to 8.6 × 10² per liter. I used these concentrations with single-hit dose-response models for all three pathogens to conduct QMRA, producing both point and interval predictions of disease rates for each outbreak. Comparison of QMRA predictions to epidemiological measurements showed good agreement; interval predictions contained measured disease rates for 9 of 12 outbreaks, with point predictions off by factors of 1.0-120 (median = 4.8). Furthermore, 11 outbreaks occurred at mean doses of less than 1 pathogen per exposure. Measured disease rates for these outbreaks were clearly consistent with a single-hit model, and not with a "two-hit" threshold model. These results demonstrate the validity of QMRA for predicting disease rates due to Cryptosporidium and Giardia.

Persistence of infectious Enterovirus within free-living amoebae - A novel waterborne risk pathway?

Free-living amoebae (FLA) are phagocytic protozoa found in natural and engineered water systems. They can form disinfectant-resistant cysts, which can harbor various human pathogenic bacteria, therefore providing them with a means of environmental persistence and dispersion through water distribution and other engineered water systems. The association of FLA with human viruses has been raised, but the limited data on the persistence of infectious virions within amoebae leaves this aspect unresolved. Enteroviruses can cause a wide range of illness and replicate in human respiratory and gastrointestinal tracts, both of which could be exposed through contact with contaminated waters if virus detection and removal are compromised by virion internalization in free-living protozoa. This is especially problematic for high-risk contaminants, such as coxsackieviruses, representative members of the Enterovirus genus that are likely infectious at low doses and cause a variety of symptoms to a vulnerable portion of the population (particularly infants). To investigate Enterovirus persistence within free-living amoebae we co-cultured an infectious clinical coxsackievirus B5 (CVB5) isolate, with the commonly reported tap water amoeba Vermamoeba vermiformis, after which we tracked virus localization and persistence in co-culture over time through a combination of advanced imaging, molecular and cell culture assays. Our results clearly demonstrate that infectious CVB5 can persist in all life stages of the amoebae without causing any visible injury to them. We also demonstrated that the amoeba generated vesicles containing virions that were expelled into the bulk liquid surroundings, a finding previously described for FLA-bacteria interactions, but not for FLA and human pathogenic viruses. Therefore, our findings suggest that the ability of CVB5 to persist in V. vermiformis could be a novel waterborne risk pathway for the persistence and dispersion of infectious human enteric viruses through water systems.

Determination of Removal Efficiencies for Escherichia coli, Clostridial Spores, and F-Specific Coliphages in Unit Processes of Surface Waterworks for QMRA Applications

The removal efficiencies of bacteria, bacterial spores, and viruses after a change in source water and water pH in coagulation were studied at pilot scale in coagulation with flotation, rapid sand filtration, and disinfection with UV and chlorine. The results were compared to the treatment efficiencies of full-scale waterworks and data from literature. A quantitative microbial risk assessment (QMRA)-method was applied to estimate the numbers of illness cases caused by Campylobacter and norovirus after simulation of six operational malfunction scenarios. Coagulation with flotation and disinfection were more efficient in removing Clostridium spp. spores and MS2 coliphages than sand filtration in the pilot scale experiments (p < 0.001–0.008). The removal of E. coli was more efficient in sand filtration and in disinfection compared to coagulation with flotation (p = 0.006 and 0.01). Source water or pH change in coagulation had not significant effects on the removal efficiency of microbes. In QMRA, when disinfection was not in use, an increase in the number of illness cases compared to the normal situation was noticed. The variability in the number of illness cases demonstrated the importance of site-specific data in QMRA. This study provides new information on applying QMRA in both pilot and full-scale waterworks.

Conceptual environmental impact assessment of a novel self-sustained sanitation system incorporating a quantitative microbial risk assessment approach

In many developing countries, including South Africa, water scarcity has resulted in poor sanitation practices. The majority of the sanitation infrastructures in those regions fail to meet basic hygienic standards. This along with the lack of proper sewage/wastewater infrastructure creates significant environmental and public health concerns. A self-sustained, waterless "Nano Membrane Toilet" (NMT) design was proposed as a result of the "Reinvent the Toilet Challenge" funded by the Bill and Melinda Gates Foundation. A "cradle-to-grave" life cycle assessment (LCA) approach was adopted to study the use of NMT in comparison with conventional pour flush toilet (PFT) and urine-diverting dry toilet (UDDT). All three scenarios were applied in the context of South Africa. In addition, a Quantitative Microbial Risk Assessment (QMRA) was used to reflect the impact of the pathogen risk on human health. LCA study showed that UDDT had the best environmental performance, followed by NMT and PFT systems for all impact categories investigated including human health, resource and ecosystem. This was mainly due to the environmental credits associated with the use of urine and compost as fertilizers. However, with the incorporation of the pathogen impact into the human health impact category, the NMT had a significant better performance than the PFT and UDDT systems, which exhibited an impact category value 4E + 04 and 4E + 03 times higher, respectively. Sensitivity analysis identified that the use of ash as fertilizer, electricity generation and the reduction of NOx emissions were the key areas that influenced significantly the environmental performance of the NMT system.

Human health impact of non-potable reuse of distributed wastewater and greywater treated by membrane bioreactors

We assessed the annual probability of infection resulting from non-potable exposures to distributed greywater and domestic wastewater treated by an aerobic membrane bioreactor (MBR) followed by chlorination. A probabilistic quantitative microbial risk assessment was conducted for both residential and office buildings and a residential district using Norovirus, Rotavirus, Campylobacter jejuni, and Cryptosporidium spp. as reference pathogens. A Monte Carlo approach captured variation in pathogen concentration in the collected water and pathogen (or microbial surrogate) treatment performance, when available, for various source water and collection scale combinations. Uncertain inputs such as dose-response relationships and the volume ingested were treated deterministically and explored through sensitivity analysis. The predicted 95th percentile annual risks for non-potable indoor reuse of distributed greywater and domestic wastewater at district and building scales were less than the selected health benchmark of 10^-4 infections per person per year (ppy) for all pathogens except Cryptosporidium spp., given the selected exposure (which included occasional, accidental ingestion), dose-response, and treatment performance assumptions. For Cryptosporidium spp., the 95th percentile annual risks for reuse of domestic wastewater (for all selected collection scenarios) and district-collected greywater were greater than the selected health benchmark when using the limited, available MBR treatment performance data; this finding is counterintuitive given the large size of Cryptosporidium spp. relative to the MBR pores. Therefore, additional data on MBR removal of protozoa is required to evaluate the proposed MBR treatment process for non-potable reuse. Although the predicted Norovirus annual risks were small across scenarios (less than 10^-7 infections ppy), the risks for Norovirus remain uncertain, in part because the treatment performance is difficult to interpret given that the ratio of total to infectious viruses in the raw and treated effluents remains unknown. Overall, the differences in pathogen characterization between collection type (i.e., office vs. residential) and scale (i.e., district vs. building) drove the differences in predicted risk; and, the accidental ingestion event (although modeled as rare) determined the annual probability of infection. The predicted risks resulting from treatment malfunction scenarios indicated that online, real-time monitoring of both the MBR and disinfection processes remains important for non-potable reuse at distributed scales. The resulting predicted health risks provide insight on the suitability of MBR treatment for distributed, non-potable reuse at different collection scales and the potential to reduce health risks for non-potable reuse.

Quantitative Microbial Risk Assessment and Opportunist Waterborne Infections⁻Are There Too Many Gaps to Fill?

Quantitative microbial risk assessment (QMRA) is a relatively new approach in identifying health risks associated with the ubiquitous presence of pathogens and opportunists in the human environment. The methodology builds on experimental and meta-analytical data to identify measurable factors that contribute to, and can quantify, the likely extent of disease given a particular exposure. Early modelling was particularly focused on food-borne disease, and subsequently water-borne disease, with the emphasis focused on ingestion and its role in enteric disease. More recently, there has been a focus on translating these principles to opportunist waterborne infections (OWI) with primary focus on Legionella spp. Whereas dose and susceptibility are well documented via the ingestion route of exposure there is considerably less certainty regarding both factors when understanding Legionella spp. and other OWI. Many OWI can arise through numerous routes of transmission with greatly differing disease presentations. Routes of Legionella spp. infection do not include ingestion, but rather aspiration and inhalation of contaminated water are the routes of exposure. The susceptible population for OWI is a vulnerable sub-set of the population unlike those associated with enteric disease pathogens. These variabilities in dose, exposure and susceptibility call in to question whether QMRA can be a useful tool in managing risks associated with OWI. Consideration of Legionella spp. as a well-documented subject of research calls into question whether QMRA of OWI is likely to be a useful tool in developing risk management strategies.

Evaluating Monitoring Strategies to Detect Precipitation-Induced Microbial Contamination Events in Karstic Springs Used for Drinking Water

Monitoring of microbial drinking water quality is a key component for ensuring safety and understanding risk, but conventional monitoring strategies are typically based on low sampling frequencies (e.g., quarterly or monthly). This is of concern because many drinking water sources, such as karstic springs are often subject to changes in bacterial concentrations on much shorter time scales (e.g., hours to days), for example after precipitation events. Microbial contamination events are crucial from a risk assessment perspective and should therefore be targeted by monitoring strategies to establish both the frequency of their occurrence and the magnitude of bacterial peak concentrations. In this study we used monitoring data from two specific karstic springs. We assessed the performance of conventional monitoring based on historical records and tested a number of alternative strategies based on a high-resolution data set of bacterial concentrations in spring water collected with online flow cytometry (FCM). We quantified the effect of increasing sampling frequency and found that for the specific case studied, at least bi-weekly sampling would be needed to detect precipitation events with a probability of >90%. We then proposed an optimized monitoring strategy with three targeted samples per event, triggered by precipitation measurements. This approach is more effective and efficient than simply increasing overall sampling frequency. It would enable the water utility to (1) analyze any relevant event and (2) limit median underestimation of peak concentrations to approximately 10%. We conclude with a generalized perspective on sampling optimization and argue that the assessment of short-term dynamics causing microbial peak loads initially requires increased sampling/analysis efforts, but can be optimized subsequently to account for limited resources. This offers water utilities and public health authorities systematic ways to evaluate and optimize their current monitoring strategies.

Toward a Comprehensive Strategy to Mitigate Dissemination of Environmental Sources of Antibiotic Resistance

Antibiotic resistance is a pervasive global health threat. To combat the spread of resistance, it is necessary to consider all possible sources and understand the pathways and mechanisms by which resistance disseminates. Best management practices are urgently needed to provide barriers to the spread of resistance and maximize the lifespan of antibiotics as a precious resource. Herein we advise upon the need for coordinated national and international strategies, highlighting three essential components: (1) Monitoring, (2) Risk Assessment, and (3) Mitigation of antibiotic resistance. Central to all three components is What exactly to monitor, assess, and mitigate? We address this question within an environmental framework, drawing from fundamental microbial ecological processes driving the spread of resistance.

Quantifying pathogen risks associated with potable reuse: A risk assessment case study for Cryptosporidium

This study evaluated the reliability and equivalency of three different potable reuse paradigms: (1) surface water augmentation via de facto reuse with conventional wastewater treatment; (2) surface water augmentation via planned indirect potable reuse (IPR) with ultrafiltration, pre-ozone, biological activated carbon (BAC), and post-ozone; and (3) direct potable reuse (DPR) with ultrafiltration, ozone, BAC, and UV disinfection. A quantitative microbial risk assessment (QMRA) was performed to (1) quantify the risk of infection from Cryptosporidium oocysts; (2) compare the risks associated with different potable reuse systems under optimal and sub-optimal conditions; and (3) identify critical model/operational parameters based on sensitivity analyses. The annual risks of infection associated with the de facto and planned IPR systems were generally consistent with those of conventional drinking water systems [mean of (9.4 ± 0.3) × 10^-5 to (4.5 ± 0.1) × 10^-4], while DPR was clearly superior [mean of (6.1 ± 67) × 10^-9 during sub-optimal operation]. Because the advanced treatment train in the planned IPR system was highly effective in reducing Cryptosporidium concentrations, the associated risks were generally dominated by the pathogen loading already present in the surface water. As a result, risks generally decreased with higher recycled water contributions (RWCs). Advanced treatment failures were generally inconsequential either due to the robustness of the advanced treatment train (i.e., DPR) or resiliency provided by the environmental buffer (i.e., planned IPR). Storage time in the environmental buffer was important for the de facto reuse system, and the model indicated a critical storage time of approximately 105 days. Storage times shorter than the critical value resulted in significant increases in risk. The conclusions from this study can be used to inform regulatory decision making and aid in the development of design or operational criteria for IPR and DPR systems.

Risk-based enteric pathogen reduction targets for non-potable and direct potable use of roof runoff, stormwater, and greywater

This paper presents risk-based enteric pathogen log reduction targets for non-potable and potable uses of a variety of alternative source waters (i.e., locally-collected greywater, roof runoff, and stormwater). A probabilistic Quantitative Microbial Risk Assessment (QMRA) was used to derive the pathogen log10 reduction targets (LRTs) that corresponded with an infection risk of either 10-4 per person per year (ppy) or 10-2 ppy. The QMRA accounted for variation in pathogen concentration and sporadic pathogen occurrence (when data were available) in source waters for reference pathogens in the genera Rotavirus, Mastadenovirus(human adenoviruses), Norovirus, Campylobacter, Salmonella, Giardia and Cryptosporidium. Non-potable uses included indoor use (for toilet flushing and clothes washing) with occasional accidental ingestion of treated non-potable water (or cross-connection with potable water), and unrestricted irrigation for outdoor use. Various exposure scenarios captured the uncertainty from key inputs, i.e., the pathogen concentration in source water; the volume of water ingested; and for the indoor use, the frequency of and the fraction of the population exposed to accidental ingestion. Both potable and non-potable uses required pathogen treatment for the selected waters and the LRT was generally greater for potable use than non-potable indoor use and unrestricted irrigation. The difference in treatment requirements among source waters was driven by the microbial quality of the water - both the density and occurrence of reference pathogens. Greywater from collection systems with 1000 people had the highest LRTs; however, those for greywater collected from a smaller population (~ 5 people), which have less frequent pathogen occurrences, were lower. Stormwater had highly variable microbial quality, which resulted in a range of possible treatment requirements. The microbial quality of roof runoff, and thus the resulting LRTs, remains uncertain due to lack of relevant pathogen data.