Identifying septic pollution exposure routes during a waterborne norovirus outbreak - A new application for human-associated microbial source tracking qPCR

In June 2017, the Pennsylvania Department of Health (PADOH) was notified of multiple norovirus outbreaks associated with 179 ill individuals who attended separate events held at an outdoor venue and campground over a month period. Epidemiologic investigations were unable to identify a single exposure route and therefore unable to determine whether there was a persistent contamination source to target for exposure mitigation. Norovirus was detected in a fresh recreational water designated swimming area and a drinking water well. A hydrogeological site evaluation suggested a nearby septic leach field as a potential contamination source via ground water infiltration. Geological characterization revealed a steep dip of the bedrock beneath the septic leach field toward the well, providing a viral transport pathway in a geologic medium not previously documented as high risk for viral ground water contamination. The human-associated microbial source tracking (MST) genetic marker, HF183, was used as a microbial tracer to demonstrate the hydrogeological connection between the malfunctioning septic system, drinking water well, and recreational water area. Based on environmental investigation findings, venue management and local public health officials implemented a series of outbreak prevention strategies including discontinuing the use of the contaminated well, issuing a permit for a new drinking water well, increasing portable toilet and handwashing station availability, and promoting proper hand hygiene. Despite the outbreaks at the venue and evidence of ground water contamination impacting nearby recreational water and the drinking water well, no new norovirus cases were reported during a large event one week after implementing prevention practices. This investigation highlights a new application for human-associated MST methods to trace hydrological connections between multiple fecal pollutant exposure routes in an outbreak scenario. In turn, pollutant source information can be used to develop effective intervention practices to mitigate exposure and prevent future outbreaks associated with human fecal contaminated waters.

Survival time of Leptospira kirschneri serovar Grippotyphosa under different environmental conditions

Leptospirosis is a re-emerging zoonotic disease of high medical importance that affects humans worldwide. Humans or animals acquire an infection with pathogenic leptospires either by direct contact with infected animals or by indirect contact to contaminated environment. Survival of Leptospira spp. in the environment after having been shed via animal urine is thus a key factor to estimate the risk of infection, but not much is known about the tenacity of pathogenic leptospires. Here, the survival time of both a laboratory strain and a field strain of L. kirschneri serovar Grippotyphosa in animal urine and their tenacity while drying was investigated and compared at different temperatures (15°C-37°C). Leptospira spp. are also often found in rivers and ponds. As the infection risk for humans and animals also depends on the spreading and survival of Leptospira spp. in these environments, the survival of L. kirschneri serovar Grippotyphosa was investigated using a 50-meter-long hose system simulating a water stream. Both strains did not survive in undiluted cattle or dog urine. Comparing different temperatures and dilution media, the laboratory strain survived the longest in diluted cattle urine with a slightly alkaline pH value (3 days), whilst the field strain survived in diluted dog urine with a slightly acid pH value up to a maximum of 24 h. Both strains did not survive drying on a solid surface. In a water stream, leptospires were able to move faster or slower than the average velocity of the water due to their intrinsic mobility but were not able to survive the mechanical damage caused by running water in the hose system. From our results we conclude, that once excreted via animal urine, the leptospires immediately need moisture or a water body to survive and stay infectious.

Point-of-Care Strategies for Detection of Waterborne Pathogens

Waterborne diseases that originated due to pathogen microorganisms are emerging as a serious global health concern. Therefore, rapid, accurate, and specific detection of these microorganisms (i.e., bacteria, viruses, protozoa, and parasitic pathogens) in water resources has become a requirement of water quality assessment. Significant research has been conducted to develop rapid, efficient, scalable, and affordable sensing techniques to detect biological contaminants. State-of-the-art technology-assisted smart sensors have improved features (high sensitivity and very low detection limit) and can perform in a real-time manner. However, there is still a need to promote this area of research, keeping global aspects and demand in mind. Keeping this view, this article was designed carefully and critically to explore sensing technologies developed for the detection of biological contaminants. Advancements using paper-based assays, microfluidic platforms, and lateral flow devices are discussed in this report. The emerging recent trends, mainly point-of-care (POC) technologies, of water safety analysis are also discussed here, along with challenges and future prospective applications of these smart sensing technologies for water health diagnostics.

Tularemia as a waterborne disease: a review

Francisella tularensis is a Gram-negative, intracellular bacterium causing the zoonosis tularemia. This highly infectious microorganism is considered a potential biological threat agent. Humans are usually infected through direct contact with the animal reservoir and tick bites. However, tularemia cases also occur after contact with a contaminated hydro-telluric environment. Water-borne tularemia outbreaks and sporadic cases have occurred worldwide in the last decades, with specific clinical and epidemiological traits. These infections represent a major public health and military challenge. Human contaminations have occurred through consumption or use of F. tularensis-contaminated water, and various aquatic activities such as swimming, canyoning and fishing. In addition, in Sweden and Finland, mosquitoes are primary vectors of tularemia due to infection of mosquito larvae in contaminated aquatic environments. The mechanisms of F. tularensis survival in water may include the formation of biofilms, interactions with free-living amoebae, and the transition to a 'viable but nonculturable' state, but the relative contribution of these possible mechanisms remains unknown. Many new aquatic species of Francisella have been characterized in recent years. F. tularensis likely shares with these species an ability of long-term survival in the aquatic environment, which has to be considered in terms of tularemia surveillance and control.

Vibrio vulnificus in aquariums is a novel threat to marine mammals and public health

Vibrio vulnificus is a Gram-negative, curved, obligate halophilic marine bacterium that exclusively exists in coastal seawaters. Previous studies revealed that V. vulnificus is one of the most dangerous foodborne zoonotic pathogens for human beings. However, it remains unknown whether marine mammals can be infected by V. vulnificus. In May 2016, a captive spotted seal (Phoca largha) died due to septicemia induced by V. vulnificus. Upon post-mortem examination, V. vulnificus was isolated, identified, and named as BJ-PH01. Further analysis showed that BJ-PH01 belongs to biotype 1 and the Clinical genotype. Furthermore, we performed an epidemiological investigation of V. vulnificus in six aquariums in northern China. As a result, V. vulnificus was successfully isolated from all investigated aquariums. The positive rates ranged from 20% to 100% in each investigated aquarium. During the investigation, 12 strains of V. vulnificus were isolated, and all 12 isolates were classified into biotype 1. Eleven of the 12 isolates belonged to the Clinical genotype, and one isolate belonged to the Environmental genotype. All 12 isolated V. vulnificus strains showed limited antibiotic resistance. Overall, our work demonstrated that V. vulnificus is frequently distributed in aquariums, thus constituting a threat to captive marine mammals and to public health.

Bio-fabrication of silver nanoparticles by Pseudomonas aeruginosa: optimisation and antibacterial activity against selected waterborne human pathogens

Multiple drug resistance and treatment of contaminated water has become a serious issue in past years. Silver nanoparticles (AgNPs), being bactericidal, non-toxic, cheap and environment friendly behaviour, have drawn attention to overcome these problems. This study has been designed to synthesise AgNPs from Pseudomonas aeruginosa. AgNPs formation was confirmed by colour change and UV-vis spectroscopy. Furthermore, Fourier transform infrared spectroscopy peaks demonstrated the presence of capped proteins as reducing and stabilising agent. Transmission electron microscopy micrograph revealed spherical shape AgNPs with the size ranging between 10 and 20 nm. Antibacterial activity of AgNPs was evaluated against the most prevalent waterborne pathogens enterohaemorrhagic Escherichia coli and Salmonellae typhimurium. Moreover, the antibacterial activity of AgNPs was tested for the treatment of contaminated water which showed attenuation in bacterial load within 8 h as demonstrated by growth kinetics data. Furthermore, AgNPs did not exhibit haemolytic effects on human red blood cells (RBCs) even at 100 mg L-1 concentration of AgNPs. The results herein suggest that AgNPs synthesised by P. aeruginosa under optimised conditions exhibit microbicidal property against waterborne pathogens and having no toxic effect on human RBCs. These AgNPs could be employed for treatment of contaminated water after process optimisation.

Waterborne Infections in Reunion Island, 2010-2017

Gram-negative bacilli Vibrio spp., Aeromonas spp., and Shewanella spp. are a major cause of severe waterborne infection. The aim of this study was to assess the clinical and microbiological characteristics and prognosis of patients hospitalized in Reunion Island for a waterborne infection. This retrospective study was conducted in the two university hospitals of Reunion Island between January 2010 and March 2017. Patients diagnosed with a Vibrio, Aeromonas, or Shewanella infection were evaluated. Over the study period, 112 aquatic strains were isolated at Reunion Island: Aeromonas spp. were found in 91 patients (81.3%), Shewanella spp. in 13 patients (11.6%), and Vibrio spp. in eight patients (7.2%). The in-hospital mortality rate was 11.6%. The main sites of infection were skin and soft tissue (44.6%) and the abdomen (19.6%). Infections were polymicrobial in 70 cases (62.5%). The most commonly prescribed empiric antibiotic regimen was amoxicillin-clavulanate (34.8%). Eighty-four percent of the aquatic strains were resistant to amoxicillin-clavulanate and more than > 95% were susceptible to third or fourth generation cephalosporins and fluoroquinolones. After multivariate analysis, the only independent risk factor of in-hospital mortality was the presence of sepsis (P < 0.0001). In Reunion Island, the most commonly isolated aquatic microorganisms were Aeromonas spp. Sepsis caused by aquatic microorganisms was frequent (> 50%) and associated with higher in-hospital mortality. This study suggests that empiric antibiotic regimens in patients with sepsis or septic shock caused by suspected aquatic microorganisms (tropical climate, skin lesion exposed to seawater…) should include broad-spectrum antibiotics (third or fourth generation cephalosporins).

A Perspective on the Global Pandemic of Waterborne Disease

Waterborne diseases continue to take a heavy toll on the global community, with developing nations, and particularly young children carrying most of the burden of morbidity and mortality. Starting with the historical context, this article explores some of the reasons why this burden continues today, despite our advances in public health over the past century or so. While molecular biology has revolutionized our abilities to define the ecosystems and etiologies of waterborne pathogens, control remains elusive. Lack of basic hygiene and sanitation, and failing infrastructure, remain two of the greatest challenges in the global fight against waterborne disease. Emerging risks continue to be the specter of multiple drug resistance and the ease with which determinants of virulence appear to be transmitted between strains of pathogens, both within and outside the human host.

Temporal Variability of Faecal Contamination from On-Site Sanitation Systems in the Groundwater of Northern Thailand

We investigated the impacts of on-site sanitation systems to local groundwater. In this year-long study, we monitored the response of faecal contamination levels to hydroclimatological factors including rainfall and groundwater table. Concentration of faecal indicators-E. coli (ESC), Enterococcus (ENT), nitrate-in thirteen pairs of shallow and deep wells were determined every 7-14 days. All samples from shallow wells were tested positive for faecal contamination (ESC and ENT > 1 MPN/100 mL) but concentration varies. A maximum of 24,000 MPN/100 mL were recorded in some shallow wells. Water from deep wells showed lower susceptibility to contamination with only 4 and 23% of samples tested positive for ESC and ENT, respectively. Concentrations of ESC and ENT were lower too, with a maximum of 5 MPN/100 mL and 28 MPN/100 mL, respectively. Fluctuation in contamination among the wells was described by four archetypal responses to hydroclimatological forcing: (i) flushing during the onset of wet season, (ii) dilution over the course of the wet season, (iii) concentration during the dry season, and (iv) synoptic response to storms. Previous studies attempting to link the prevalence of faecal/waterborne diseases and temporal factors (e.g., dry vs wet season) have produced differing outcomes. Our study may help explain the relevant hydrological mechanisms leading to these varying observations. Presently, most communities in Thailand have access to 'improved' sanitation systems. However, due to the unsustainable implementation of these systems, the otherwise viable drinking-water resources in the form of the abundant local groundwater has become a genuine health hazard.

Virus-Bacteria Interactions: Implications and Potential for the Applied and Agricultural Sciences

Eukaryotic virus-bacteria interactions have recently become an emerging topic of study due to multiple significant examples related to human pathogens of clinical interest. However, such omnipresent and likely important interactions for viruses and bacteria relevant to the applied and agricultural sciences have not been reviewed or compiled. The fundamental basis of this review is that these interactions have importance and deserve more investigation, as numerous potential consequences and applications arising from their discovery are relevant to the applied sciences. The purpose of this review is to highlight and summarize eukaryotic virus-bacteria findings in the food/water, horticultural, and animal sciences. In many cases in the agricultural sciences, mechanistic understandings of the effects of virus-bacteria interactions remain unstudied, and many studies solely focus on co-infections of bacterial and viral pathogens. Given recent findings relative to human viral pathogens, further research related to virus-bacteria interactions would likely result in numerous discoveries and beneficial applications.

Effects of Boiling Drinking Water on Diarrhea and Pathogen-Specific Infections in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Globally, approximately 2 billion people lack microbiologically safe drinking water. Boiling is the most prevalent household water treatment method, yet evidence of its health impact is limited. To conduct this systematic review, we searched four online databases with no limitations on language or publication date. Studies were eligible if health outcomes were measured for participants who reported consuming boiled and untreated water. We used reported and calculated odds ratios (ORs) and random-effects meta-analysis to estimate pathogen-specific and pooled effects by organism group and nonspecific diarrhea. Heterogeneity and publication bias were assessed using I2, meta-regression, and funnel plots; study quality was also assessed. Of the 1,998 records identified, 27 met inclusion criteria and reported extractable data. We found evidence of a significant protective effect of boiling for Vibrio cholerae infections (OR = 0.31, 95% confidence interval [CI] = 0.13-0.79, N = 4 studies), Blastocystis (OR = 0.35, 95% CI = 0.17-0.69, N = 3), protozoal infections overall (pooled OR = 0.61, 95% CI = 0.43-0.86, N = 11), viral infections overall (pooled OR = 0.83, 95% CI = 0.7-0.98, N = 4), and nonspecific diarrheal outcomes (OR = 0.58, 95% CI = 0.45-0.77, N = 7). We found no evidence of a protective effect for helminthic infections. Although our study was limited by the use of self-reported boiling and non-experimental designs, the evidence suggests that boiling provides measureable health benefits for pathogens whose transmission routes are primarily water based. Consequently, we believe a randomized controlled trial of boiling adherence and health outcomes is needed.

Mortality from selected diseases that can be transmitted by water - United States, 2003-2009

Diseases spread by water are caused by fecal-oral, contact, inhalation, or other routes, resulting in illnesses affecting multiple body systems. We selected 13 pathogens or syndromes implicated in waterborne disease outbreaks or other well-documented waterborne transmission (acute otitis externa, Campylobacter, Cryptosporidium, Escherichia coli (E. coli), free-living ameba, Giardia, Hepatitis A virus, Legionella (Legionnaires' disease), nontuberculous mycobacteria (NTM), Pseudomonas-related pneumonia or septicemia, Salmonella, Shigella, and Vibrio). We documented annual numbers of deaths in the United States associated with these infections using a combination of death certificate data, nationally representative hospital discharge data, and disease-specific surveillance systems (2003-2009). We documented 6,939 annual total deaths associated with the 13 infections; of these, 493 (7%) were caused by seven pathogens transmitted by the fecal-oral route. A total of 6,301 deaths (91%) were associated with infections from Pseudomonas, NTM, and Legionella, environmental pathogens that grow in water system biofilms. Biofilm-associated pathogens can cause illness following inhalation of aerosols or contact with contaminated water. These findings suggest that most mortality from these 13 selected infections in the United States does not result from classical fecal-oral transmission but rather from other transmission routes.

Safe drinking water and waterborne outbreaks

The present work compiles a review on drinking waterborne outbreaks, with the perspective of production and distribution of microbiologically safe water, during 2000-2014. The outbreaks are categorised in raw water contamination, treatment deficiencies and distribution network failure. The main causes for contamination were: for groundwater, intrusion of animal faeces or wastewater due to heavy rain; in surface water, discharge of wastewater into the water source and increased turbidity and colour; at treatment plants, malfunctioning of the disinfection equipment; and for distribution systems, cross-connections, pipe breaks and wastewater intrusion into the network. Pathogens causing the largest number of affected consumers were Cryptosporidium, norovirus, Giardia, Campylobacter, and rotavirus. The largest number of different pathogens was found for the treatment works and the distribution network. The largest number of affected consumers with gastrointestinal illness was for contamination events from a surface water source, while the largest number of individual events occurred for the distribution network.

Small Intestinal Infections

Small intestinal infections are extremely common worldwide. They may be bacterial, viral, or parasitic in etiology. Most are foodborne or waterborne, with specific etiologies differing by region and with diverse pathophysiologies. Very young, very old, and immune-deficient individuals are the most vulnerable to morbidity or mortality from small intestinal infections. There have been significant advances in diagnostic sophistication with the development and early application of molecular diagnostic assays, though these tests have not become mainstream. The lack of rapid diagnoses combined with the self-limited nature of small intestinal infections has hampered the development of specific and effective treatments other than oral rehydration. Antibiotics are not indicated in the absence of an etiologic diagnosis, and not at all in the case of some infections.

The impact of meteorology on the occurrence of waterborne outbreaks of vero cytotoxin-producing Escherichia coli (VTEC): a logistic regression approach

This study analyses the relationship between meteorological phenomena and outbreaks of waterborne-transmitted vero cytotoxin-producing Escherichia coli (VTEC) in the Republic of Ireland over an 8-year period (2005-2012). Data pertaining to the notification of waterborne VTEC outbreaks were extracted from the Computerised Infectious Disease Reporting system, which is administered through the national Health Protection Surveillance Centre as part of the Health Service Executive. Rainfall and temperature data were obtained from the national meteorological office and categorised as cumulative rainfall, heavy rainfall events in the previous 7 days, and mean temperature. Regression analysis was performed using logistic regression (LR) analysis. The LR model was significant (p < 0.001), with all independent variables: cumulative rainfall, heavy rainfall and mean temperature making a statistically significant contribution to the model. The study has found that rainfall, particularly heavy rainfall in the preceding 7 days of an outbreak, is a strong statistical indicator of a waterborne outbreak and that temperature also impacts waterborne VTEC outbreak occurrence.

Associations between Self-Reported Gastrointestinal Illness and Water System Characteristics in Community Water Supplies in Rural Alabama: A Cross-Sectional Study

BACKGROUND

Community water supplies in underserved areas of the United States may be associated with increased microbiological contamination and risk of gastrointestinal disease. Microbial and health risks affecting such systems have not been systematically characterized outside outbreak investigations. The objective of the study was to evaluate associations between self-reported gastrointestinal illnesses (GII) and household-level water supply characteristics.

METHODS

We conducted a cross-sectional study of water quality, water supply characteristics, and GII in 906 households served by 14 small and medium-sized community water supplies in Alabama's underserved Black Belt region.

RESULTS

We identified associations between respondent-reported water supply interruption and any symptoms of GII (adjusted odds ratio (aOR): 3.01, 95% confidence interval (CI) = 1.65-5.49), as well as low water pressure and any symptoms of GII (aOR: 4.51, 95% CI = 2.55-7.97). We also identified associations between measured water quality such as lack of total chlorine and any symptoms of GII (aOR: 5.73, 95% CI = 1.09-30.1), and detection of E. coli in water samples and increased reports of vomiting (aOR: 5.01, 95% CI = 1.62-15.52) or diarrhea (aOR: 7.75, 95% CI = 2.06-29.15).

CONCLUSIONS

Increased self-reported GII was associated with key water system characteristics as measured at the point of sampling in a cross-sectional study of small and medium water systems in rural Alabama in 2012 suggesting that these water supplies can contribute to endemic gastro-intestinal disease risks. Future studies should focus on further characterizing and managing microbial risks in systems facing similar challenges.

[DISTRIBUTION OF BACTERIA OF THE KLEBSIELLA STRAIN IN WATER OBJECTS AND THEIR VALUE IN DEVELOPING OF THE WATER CAUSED ACUTE INTESTINAL INFECTIONS]

The wide circulation of Klebsiella bacteria in water ofwater objects of different climatic zones of Russia and various function is established. So bacteria of the Klebsiella strain are in superficial sources of the centralized water supply depending on extent of their biological and chemical pollution; underground waters at the unprotected water-bearing horizons; in drinking water at insufficiently effective system of its cleaning and disinfecting. Klebsiella circulating in water was shown to keep properties of pathogenicity and a virulence, possess resistance both to modern preparations and disinfecting agents (chlorine, an ultraviolet to radiation). Bacteria of the Klebsiella strain have high penetration in the water-bearing horizons. At strains of Klebsiella there is allocated considerable pathogenic potential (adhesive, invasive, phosphatase, lecithinase, DNA-ase, hemolytic activity) and genetic markers of pathogenicity of cnf-1. The etiologic role of bacteria of Klebsiella and an infecting (100, COE/dm3) dose emergence of acute intestinal infections (AII) is established. Detection of Klebsiella in water objects and especially in water of drinking appointment, in the absence of total coliform bacteria (TCB) contributes to the epidemic danger of water use.

Analytical studies assessing the association between extreme precipitation or temperature and drinking water-related waterborne infections: a review

Determining the role of weather in waterborne infections is a priority public health research issue as climate change is predicted to increase the frequency of extreme precipitation and temperature events. To document the current knowledge on this topic, we performed a literature review of analytical research studies that have combined epidemiological and meteorological data in order to analyze associations between extreme precipitation or temperature and waterborne disease.A search of the databases Ovid MEDLINE, EMBASE, SCOPUS and Web of Science was conducted, using search terms related to waterborne infections and precipitation or temperature. Results were limited to studies published in English between January 2001 and December 2013.Twenty-four articles were included in this review, predominantly from Asia and North-America. Four articles used waterborne outbreaks as study units, while the remaining articles used number of cases of waterborne infections. Results presented in the different articles were heterogeneous. Although most of the studies identified a positive association between increased precipitation or temperature and infection, there were several in which this association was not evidenced. A number of articles also identified an association between decreased precipitation and infections. This highlights the complex relationship between precipitation or temperature driven transmission and waterborne disease. We encourage researchers to conduct studies examining potential effect modifiers, such as the specific type of microorganism, geographical region, season, type of water supply, water source or water treatment, in order to assess how they modulate the relationship between heavy rain events or temperature and waterborne disease. Addressing these gaps is of primary importance in order to identify the areas where action is needed to minimize negative impact of climate change on health in the future.