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   [email protected]   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 $billions to maintain •  Sewer/septic system releases – major cause of eutrophication •  Neither climate/demographic resilient nor economic 4   [email protected]   2 !"#$%&'%($)"(*)!"#$%+,"-$*)./0%'&/"1)2"#3'4$(-5)6%70)8'99:(/#;)!"#$%))<"(/#"7'(! "#$#%&!!'(!)*+,! Nature of the WASH problem • Developed countries: treated DW, flush toilet- ! sewerage; yet most expensive option1 ($160k/h2) • 32-36% of global pop lack household-level ! access to safe water or hygienic toilets3 • 1.5 B people in developing regions use ! sanitation systems that do not protect others3 • Hence, promotion of urine-diverting toilets, ! blackwater to biogas, dry composting toilets! +@//=!!"#$%&!L)*+,M!N!O<PH5/<!Q3<3$4!+,*(!K''R,'! )S/%&!B45!-/#%4!H<!5#530!"03%D3!&/!B5/PH=4!BHB4=!>3&45:%4>3$4!! KS#AAH<$!!"#$%&#L)*+'M!FT/8!U<4!!V!L+)M(!4++'WVV! @) Cleaning vs. Hygiene • Meta-analysis of impact of cleaning and disease ! reduction indicates normal household cleaning may increase illness rates (Paul Hunter) S043<H<$!30/<4!A3X!H<7543%4!5H%D%!.X!%B543=H<$!B3&-/$4<%! !"#$%&'()(*#+','-./0"#1/#2/0-#+&'%1+3# A) "%-./0&1230.45&3673! K! 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   [email protected]   4 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   [email protected]   5 !"#$%&'%($)"(*)!"#$%+,"-$*)./0%'&/"1)2"#3'4$(-5)6%70)8'99:(/#;)!"#$%))<"(/#"7'(! "#$#%&!!'(!)*+,! Importance of minor human impact • Most epidemiology G=FH)3:9"()$(#$%'0'00/)9";&$)-/45) ! I28J).<K)('#)#3"#)L%$0/-$M) studies for rec water lacked statistical power, nor were •!!46$6!/<4!(cid:1)934730(cid:2)!377H=4<&!7/#0=!54%#0&!H<! +*KR+*,!PH5H/<%!TR+!!H<!3<!U0XABH7!B/,/RV0!,bH04! they designed to •!H646!745&3H<!&/!73#%4!H<947C/<! specifically %!! % 4 < _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%! EE) 87-/4<!e!"%-./0&!L)*+*M!O<PH5/<!87H!Z47-!''[))fWRV+! EE) 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=) "%-./0&1230.45&3673! W! 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/ $195M *Collier et al. (2012) Epi Inf 140(11): 2003-13 13   Sequelae •  Disease that develops only after initial infection has occurred •  This can occur days, weeks or years after initial infection •  Examples: auto-immune disease Ø  Diabetes Ø  Heart disease Ø  Liver damage Ø  Reactive arthritis 14   [email protected]   7 !"#$%&'%($)"(*)!"#$%+,"-$*)./0%'&/"1)2"#3'4$(-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   [email protected]   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   [email protected]   10