Nick Ashbolt - Waterborne and Water-Based Microbial Pathogens

31 Pages·2015·3.76 MB·English

by  Nicholas Ashbolt

Waterborne
 and
 Water-­‐Based
 Microbial
 Pathogens:
 Ar7c
 Community
 Water

 Sanita7on
  August

 4,
 2015

[email protected]

Waterborne and Water-Based
Microbial Pathogens: Artic
Community Water and Sanitation
Nicholas Ashbolt, Alberta Innovates Health
Solutions Translational Health Chair in Water
Waterborne disease history
•  1854 – John Snow links cholera & water in UK
•  1854 / 1884 cholera bacteria isolated/described
•  1900 – Filtration of water supplies begins in the
North America – major drop in typhoid &
cholera observed in cities using filtration
•  1909 – Chlorination of water supplies begins in
the United States – further drop
•  1993 – Largest waterborne outbreak every
documented in the United States ~ 400,000 ill
and 97 die – Cryptosporidium hominis
•  2009 –Largest swimming outbreak in history
~4,000 ill – Cryptosporidium hominis
2

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  1
Waterborne
 and
 Water-­‐Based
 Microbial
 Pathogens:
 Ar7c
 Community
 Water

 Sanita7on
  August

 4,
 2015

Death rate from typhoid/cholera
USA 1900-1960
3

Traditional domestic water services
Surface/

Ground
  Water

  Household

water
  treatment

Pathogens

Nutrients

SepCc
 tank
 /
  Drugs

Challenges leachfield
  Biocides

•  Water services use 3-7% of a nation’s electricity (yield 3% GHG)
• vs 14% for hot water (household heating 29% & cooling 17%)
•  Aging water and wastewater infrastructure $billions to maintain
•  Sewer/septic system releases – major cause of eutrophication
•  Neither climate/demographic resilient nor economic
4

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Nature of the WASH problem
• Developed countries: treated DW, flush toilet-
!
sewerage; yet most expensive option1 ($160k/h2)
• 32-36% of global pop lack household-level
!
access to safe water or hygienic toilets3
• 1.5 B people in developing regions use
!
sanitation systems that do not protect others3
• Hence, promotion of urine-diverting toilets,
!
blackwater to biogas, dry composting toilets!
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@)
Cleaning vs. Hygiene
• Meta-analysis of impact of cleaning and disease
!
reduction indicates normal household cleaning
may increase illness rates (Paul Hunter)
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Waterborne
 and
 Water-­‐Based
 Microbial
 Pathogens:
 Ar7c
 Community
 Water

 Sanita7on
  August

 4,
 2015

Some facts about environmentally
transmitted illness
•  80% of all infectious diseases environmentally
transmitted
•  You will experience viral illness 10% of your lifetime
•  In the United States you will have a foodborne
illness at least every 5 to 6 years (~46 million / y)
•  Most colds and flu are transmitted by fomites
•  Children experience 3-6 respiratory infection per
year. Adults 1 to 3 per year
(Chuck
 Gerba
 pers.
 Comm.)

7

Generally can not solely rely on
outbreak data to estimate risks
[Total:reported
 case
 10
 to
 500:1]

s Outbreak detected
e
s Threshold for detection for an outbreak
a
C

f
o
Undetected outbreak
er Endemic Sporadic
b
rate
m Hyperendemic
u
N
Time
Frost et al. (1996) J AWWA 88(9): 66-75
8

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Waterborne
 and
 Water-­‐Based
 Microbial
 Pathogens:
 Ar7c
 Community
 Water

 Sanita7on
  August

 4,
 2015

French cohort DW outbreak vs AGI drug use
Mouly et al. 2015 Epi Inf 10.1017/S0950268815001673
French
 NaConal

Health
 Insurance

InformaCon

A‘ach
 rate
 from
 drinking
 water
 with

System
 (SNIIRAM)

>
 100
 E.
 coli
 /
 100
 mL

 1-­‐10%

Campylobacter
 sp.
 via
 mountain

spring
 (1067
 people,
 39·∙6%
 studied)

9

How much illness via US tap water?
•  Municipal drinking water cases of diarrhea
– 12 million cases/y (Colford et al. 2006)
– 16 million cases/y (Messner et al. 2006)
– 19.5 million in municipal & individual systems
(Reynolds et al. 2007)
– 24 million waterborne+water-based (Gerba, 2012)
•  5,000 deaths/y CDC (waterborne organisms)
•  7,000 to 20,000 deaths/y by water-based
pathogens (CDC, 2012)
10

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  5
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Importance of minor human impact
• Most epidemiology G=FH)3:9"()$(#$%'0'00/)9";&$)-/45)
!
I28J).<K)('#)#3"#)L%$0/-$M)
studies for rec water
lacked statistical
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+*KR+*,!PH5H/<%!TR+!!H<!3<!U0XABH7!B/,/RV0!,bH04!
they designed to
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specifically %!!
%
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< _H%D!95/A!%4>3$4!
investigate health ;^!^00
relationships to .6!
/ _H%D!95/A!$#00%!
fecal indicators as F5!!!!
3%%#AH<$!)*b!-#A3<!H<947C/#%!
well as bather
density or other
faecal source mixes
b!/9!K,!4<&!:+**!AT!95/A!$#00%!
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Disease agents from 780 drinking
wwaatteerr oouuttbbrreeaakkss,, 11997711--22000066 UUSSAA
(28% since 20!!!01)
D/E:F&'5*'
B/-C.:.&'6*' !"#$%&"''(!
(85% Norovirus) !U"n#k"n$%ow"&n'(,) 4*5'%
=>:?/1,@.&'5A*'
(30% Cu, 12% F,
9% NO - )
3
7$"8!"#$%&"''('
9,13:-/,;'5<*'
Craun et al. (2010)
Clin Microbiol Rev
+,-,./01' (403,000 cases from a single outbreak of
23: 507-528
2-$3$4$,&'56*' Cryptosporidium hominis in Milwaukee (WI) Apri l
1993, but only 9% of outbreaks vs. Giardia 86%)
E=)
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Waterborne
 and
 Water-­‐Based
 Microbial
 Pathogens:
 Ar7c
 Community
 Water

 Sanita7on
  August

 4,
 2015

Public health hospitalization costs
associated with US drinking water*
•  CDC estimate drinking water disease costs > $970 m/y
– Less so faecal pathogens, largely Legionnaires’
disease, otitis externa, and non-tuberculous
mycobacterial (NTM) giving >40 000 hospitalizations/y
Disease Annual costs
Cryptosporidiosis $46M
Giardiasis $34M
Legionnaires’ disease $434M
NTM infection/Pulmonary $426M/ $195M
*Collier et al. (2012) Epi Inf 140(11): 2003-13
13

Sequelae
•  Disease that develops only after
initial infection has occurred
•  This can occur days, weeks or years
after initial infection
•  Examples: auto-immune disease
Ø  Diabetes
Ø  Heart disease
Ø  Liver damage
Ø  Reactive arthritis
14

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  7
!"#$%&'%($)"(*)!"#$%+,"-$*)./0%'&/"1)2"#3'4$(-5)6%70)8'99:(/#;)!"#$%))<"(/#"7'(! "#$#%&!!'(!)*+,!
VVaarriioouuss ppaatthhooggeenn sseeqquueellaaee
• Carcinogens
!
– Helicobacter pylori, ccyyaannoottooxxiinnss
!
• Teratogens
!
– Toxoplasma gondii
!
– Coxsackievirus
!
• Renal disease
!
– E. coli O157:H7, MMiiccrroossppoorriiddiiuumm sspppp..
!
• Hepatogens
!
– Hepatitis A & E viruses, ccyyaannoottooxxiinnss
!
E@)
Various pathogen sequelae
• Nervous system disorders
!
– Campylobacter jejuni, various Enterovirus spp.
!
• Heart disease
!
– Adenovirus, Coxsackievirus
!
• Endocrine disrupters
!
– Coxsackievirus – Orchitis
!
– Yesinia enterocolita – Grave’s Disease
!
– Giardia lamblia - hypothyroidism
!
– Helicobacter pylori - atrophic thyroiditis ?
!
EA)
"%-./0&1230.45&3673! f!
Waterborne
 and
 Water-­‐Based
 Microbial
 Pathogens:
 Ar7c
 Community
 Water

 Sanita7on
  August

 4,
 2015

WHO’s new focus: global AMR
•  3rd gen cephalosporin-resistant
E. coli & MRSA predicted deaths
3.3 per 100,000 in EU in 2015*
•  Globally 700,000 AMR-deaths,
some 10 million by 2050**
•  Unclear fraction due to water*
*Ashbolt
 et
 al.
 (2013)
 Env
 Health
 Perspect
 121(9),
 993-­‐1001

**Hoffman
 et
 al.
 (2015)
 Bull
 WHO
 3(2),
 66

17

Antibiotic-resistant bacteria via
drinking water?
•  Fat Drugs (antibiotics promote child weight)
–  Used in agriculture for weight gain
–  Part of the human obesity problem
•  Primary waterborne sources include
–  Wastewater (industry & hospitals)
–  Animal production/manures
•  Mass delivery via water?
–  Water disinfectants and metal pipes
known to increase gene exchange within
biofilms loss of AB efficacy
Cox
 &
 Blaser
 (2013)
 Cell
 Metab
 17:
 883-­‐94

Gough
 et
 al.
 (2014)
 BMJ
 348:
 g2267
  Kennedy
 (2014)
 NYTimes
 8
 March

18

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  9
Waterborne
 and
 Water-­‐Based
 Microbial
 Pathogens:
 Ar7c
 Community
 Water

 Sanita7on
  August

 4,
 2015

Health hazards in drinking waters
•  Pathogens generally a significantly greater risk than
chemicals via water/sanitation (despite chem focus*)
•  Helminths largely impact via direct faecal contact
•  U.S. EPA Safe Drinking Water Act & Health Canada require
(based on quantitative microbial risk assessment QMRA):
–  4-log (99.99%) reduction of enteric viruses and 3-log (99.9%) for
10 10
parasitic protozoa; and verification with no E. coli per 100 mL from
surface water supplies (monitoring if supplied to > 25 people)
–  To give: annual risks < 1 infection / 10,000/y or < 1 microDALY/y
Ø Proposed Arctic household D water: MF/UF + UV > 4-log
10
(virus, parasite, bacteria), i.e. generally better than required
*ArcCc
 Monitoring
 and
 Assessment
 Programme
 (Donaldson
 et
 al.
 2010
 SOTE
 408:
 5165-­‐234)

19

Acceptable or tolerable risk
•  Haas (1996) describes 1980’s EPA
Surface Water Treatment Rule, 10-4 per y:
– current practices (late 1980’s) considered to be
producing water of acceptable level of risk
– reported outbreak caseloads approximated one
illness per 10,000 per annum
– infection rather than illness, since many illnesses
go unreported & so covers the more susceptible
– lifetime risk of death due to waterborne infections
at a 1:10,000 level estimated 10-6-10-5 range,
which was in line with chemical risk assessment
20

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