Quantitative risk assessment of Cryptosporidium in tap water in Ireland

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.

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.

Risk assessment of Cryptosporidium intake in drinking water treatment plant by a combination of predictive models and event-tree and fault-tree techniques

Risk-informed decision making permits a more effective water safety management. In this framework, this article introduces the rationale and proposes a new approach to carry out a quantitative risk assessment along the water chain, from river source to tap water, by integrating predictive modelling combined with event-tree and fault-tree techniques. The model developed by this approach could not only account for normal but also for abnormal process conditions in the water treatment plant, as well as assess the real impact of the applied safety controls, such as turbidity control. A sensitivity study was conducted to determine the effect of considering a typical drinking water treatment plant (DWTP), i.e. coagulation, sedimentation and filtration with two turbidity controls (on intake and after filtration) on the risk of infection due to exposure to Cryptosporidium in tap water. The results showed that, with the current effectiveness of turbidity reduction in the DWTP, the first control did not minimise the annual risk of Cryptosporidium infection (3.6E-04) and only limiting turbidity after filtration to below 0.01NTU provided a clear reduction in risk (7.7E-05) at the cost of rejecting 60 % of the water after the control. The lowest risk was found when turbidity reduction was set at 4 logs (8.48E-06), although this means that the effectiveness of turbidity reduction should be greatly improved. It was therefore concluded that supplementing the current treatment with alternative barriers such as UV or ozone disinfection and/or implementing direct control of Cryptosporidium concentration should be considered.

Risk factors and assessment strategies for the evaluation of human or environmental risk from metal(loid)s - A focus on Ireland

Elevated human exposure to metals and metalloids (metal(loid)s) may lead to acute sickness and pose a severe threat to human health. The human body is exposed to metal(loid)s principally through food, water, supplements, and (occasionally) air. There are inherent background levels of many metal(loid)s in regional soils as a consequence of geological sources. Baseline levels coupled with anthropogenic sources such as regional application of biosolids may lead to increased levels of certain metal(loid)s in soil, leading to potential transfer to water sources and potential uptake by plants. The latter could potentially transfer into the feed-to-food chain, viz. grazing animals, and bio-transfer to food products resulting in human exposure. This study addresses health concerns due to excessive intake of metal(loid)s by conducting a traditional review of peer-reviewed journals between 2015 and 2019, secondary references and relevant websites. The review identified the most researched metal(loid)s as Cu, Zn, Pb, Cd, Ni, Cr, As, Hg, Mn, Fe in the environment. The potential uptake of metal(loid)s by plants (phytoavailability) is a function of the mobility/retainability of metal(loid)s in the soil, influenced by soil geochemistry. The most critical parameters (including soil pH, soil organic matter, clay content, cation exchange capacity, the capability of decomposition of organic matter by microbes, redox potential, ionic strength) influencing metal(loid)s in soil are reviewed and used as a foundation to build a framework model for ranking metal(loid)s of concern. A robust quantitative risk assessment model is recommended for evaluating risk from individual metal(loid)s based on health-based indices (Daily Dietary Index (DDI), No Observed Adverse Effect Level (NOAEL), and Lowest Observed Adverse Effect Level (LOAEL)). This research proposes a risk assessment framework for potentially harmful metal(loid)s in the environment and highlights where regulation and intervention may be required.

Quantitative microbial human exposure model for faecal indicator bacteria and risk assessment of pathogenic Escherichia coli in surface runoff following application of dairy cattle slurry and co-digestate to grassland

Animal waste contains high numbers of microorganisms and therefore can present a potential biological threat to human health. During episodic rainfall events resulting in runoff, microorganisms in the waste and soil may migrate into surface runoff, contaminating surface water resources. A probabilistic human exposure (HE) model was created to determine exposure to faecal indicator bacteria (FIB): total coliforms (TC), E. coli and enterococci following application of bio-based fertiliser (dairy cattle slurry, digestate) to grassland; using a combination of experimental field results and literature-based data. This step was followed by a quantitative microbial risk assessment (QMRA) model for pathogenic E. coli based on a literature-based dose-response model. The results showed that the maximum daily HE (HE_daily) is associated with E. coli for unprocessed slurry (treatment T1) on day 1, the worst-case scenario where the simulated mean HE_daily was calculated as 2.84 CFU day ^-1. The results indicate that the overall annual probability of risk (P_annual) of illness from E. coli is very low or low based on the WHO safe-limit of P_annual as 10 ^-6. In the worst-case scenario, a moderate risk was estimated with simulated mean P_annual as 1.0 × 10 ^-5. Unpasteurised digestate application showed low risk on day 1 and 2 (1.651 × 10 ^-6, 1.167 × 10 ^-6, respectively). Pasteurised digestate showed very low risk in all scenarios. These results support the restriction imposed on applying bio-based fertiliser if there is any rain forecast within 48 h from the application time. This study proposes a future extension of the probabilistic model to include time, intensity, discharge, and distance-dependant dilution factor. The information generated from this model can help policymakers ensure the safety of surface water sources through the quality monitoring of FIB levels in bio-based fertiliser.

Spatiotemporal epidemiology of cryptosporidiosis in the Republic of Ireland, 2008-2017: development of a space-time "cluster recurrence" index

Background

Ireland frequently reports the highest annual Crude Incidence Rates (CIRs) of cryptosporidiosis in the EU, with national CIRs up to ten times the EU average. Accordingly, the current study sought to examine the spatiotemporal trends associated with this potentially severe protozoan infection.

Methods

Overall, 4509 cases of infection from January 2008 to December 2017 were geo-referenced to a Census Small Area (SA), with an ensemble of geo-statistical approaches including seasonal decomposition, Local Moran’s I, and space–time scanning used to elucidate spatiotemporal patterns of infection.

Results

One or more confirmed cases were notified in 3413 of 18,641 Census SAs (18.3%), with highest case numbers occurring in the 0–5-year range (n = 2672, 59.3%). Sporadic cases were more likely male (OR 1.4) and rural (OR 2.4), with outbreak-related cases more likely female (OR 1.4) and urban (OR 1.5). Altogether, 55 space–time clusters (≥ 10 confirmed cases) of sporadic infection were detected, with three “high recurrence” regions identified; no large urban conurbations were present within recurrent clusters.

Conclusions

Spatiotemporal analysis represents an important indicator of infection patterns, enabling targeted epidemiological intervention and surveillance. Presented results may also be used to further understand the sources, pathways, receptors, and thus mechanisms of cryptosporidiosis in Ireland.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06598-3.

Co-infection risk assessment of Giardia and Cryptosporidium with HIV considering synergistic effects and age sensitivity using disability-adjusted life years

Co-infection with multiple pathogens, especially the spread of Giardia and Cryptosporidium in source water among those with immunodeficiency, is common worldwide, which will result in an increase in overall risk. In this study, the quantitative microbial risk assessment model was used to estimate the cumulative risk of co-infection with Giardia and Cryptosporidium promoted by HIV, considering age sensitivity. The sensitivity of population segments with different ages was estimated by the optimization method, based on clinical data of cryptosporidiosis and giardiasis with age structure. The factors of co-infection enhancement were used to quantify HIV synergism with the action of other pathogens. The removal rates of Giardia and Cryptosporidium through water treatment were estimated by a model involving turbidity and particles. The results showed that children (0-4 years) were 17.911-fold more sensitive to infection with Giardia than adults (15-64 years), and that with Cryptosporidium was 10.592-fold. Removal rates of these parasites in water treatment plants in major cities in China were estimated to be 2.03 log₁₀. Considering the HIV-synergistic and age-susceptibility effects, the cumulative risk of exposure to Giardia or Cryptosporidium was about 38.781 × 10^-6DALYs (Disability-adjusted life years) per person per year, which was much higher than the reference risk level recommended by the World Health Organization (10^-6DALYs). The methodology and results of this study will be useful in better evaluating and reducing the burden due to infection of Giardia and/or Cryptosporidium in China and other countries.

An exploration of the disease burden due to Cryptosporidium in consumed surface water for sub-Saharan Africa

The protozoan pathogen Cryptosporidium is an important cause of diarrhoeal disease, but in many contexts its burden remains uncertain. The Global Waterborne Pathogen model for Cryptosporidium (GloWPa-Crypto) predicts oocyst concentrations in surface water at 0.5 by 0.5° (longitude by latitude) resolution, allowing us to assess the burden specifically associated with the consumption of contaminated surface water at a large scale. In this study, data produced by the GloWPa-Crypto model were used in a quantitative microbial risk assessment (QMRA) for sub-Saharan Africa, one of the regions most severely affected by diarrhoeal disease. We first estimated the number of people consuming surface water in this region and assessed both direct consumption and consumption from a piped (treated) supply. The disease burden was expressed in disability adjusted life years (DALYs). We estimate an annual number of 4.3 × 10⁷ (95% uncertainty interval [UI] 7.4 × 10⁶-5.4 × 10⁷) cases which represent 1.6 × 10⁶ (95% UI 3.2 × 10⁵-2.3 × 10⁶) DALYs. Relative disease burden (DALYs per 100,000 persons) varies widely, ranging between 1.3 (95% UI 0.1-5.7) for Senegal and 1.0 × 10³ (95% UI 4.2 × 10²-1.4 × 10³) for Eswatini. Countries that carry the highest relative disease burden are primarily located in south and south-east sub-Saharan Africa and are characterised by a relatively high HIV/AIDS prevalence. Direct surface water consumption accounts for the vast majority of cases, but the results also point towards the importance of stable drinking water treatment performance. This is, to our knowledge, the first study to utilise modelled data on pathogen concentrations in a large scale QMRA. It demonstrates the potential value of such data in epidemiological research, particularly regarding disease aetiology.

Quantitative microbial risk assessment and its applications in small water systems: A review

Quantitative microbial risk assessment (QMRA) has been mainstreamed in many large municipal water systems as part of a paradigm shift in the drinking water industry towards water safety planning and risk-based system assessment. Small water systems (SWSs) are generally more vulnerable to typical water system hazards, and consequently have a higher risk of waterborne disease outbreak. In this paper, a review of experiences in implementing QMRA in SWSs helps elaborate the sources of risks and highlights some of the challenges facing SWSs in developed countries. A critical review of the important elements for practical implementation of QMRA was conducted. The investigation focuses on aspects related to challenges in identifying relevant hazards to SWSs to create failure scenarios, acquiring monitoring data for pathogens' concentrations in source water, estimating treatment efficiencies of typical small system technologies, and access to software tools to support successful implementation. The review helped outline ways through which SWSs can overcome the identified challenges in implementing QMRA. An adjusted framework for implementing QMRA for small water systems was formulated and discussed.

Development and Application of a Probabilistic Risk-Benefit Assessment Model for Infant Feeding Integrating Microbiological, Nutritional, and Chemical Components

A probabilistic and interdisciplinary risk-benefit assessment (RBA) model integrating microbiological, nutritional, and chemical components was developed for infant milk, with the objective of predicting the health impact of different scenarios of consumption. Infant feeding is a particular concern of interest in RBA as breast milk and powder infant formula have both been associated with risks and benefits related to chemicals, bacteria, and nutrients, hence the model considers these three facets. Cronobacter sakazakii, dioxin-like polychlorinated biphenyls (dl-PCB), and docosahexaenoic acid (DHA) were three risk/benefit factors selected as key issues in microbiology, chemistry, and nutrition, respectively. The present model was probabilistic with variability and uncertainty separated using a second-order Monte Carlo simulation process. In this study, advantages and limitations of undertaking probabilistic and interdisciplinary RBA are discussed. In particular, the probabilistic technique was found to be powerful in dealing with missing data and to translate assumptions into quantitative inputs while taking uncertainty into account. In addition, separation of variability and uncertainty strengthened the interpretation of the model outputs by enabling better consideration and distinction of natural heterogeneity from lack of knowledge. Interdisciplinary RBA is necessary to give more structured conclusions and avoid contradictory messages to policymakers and also to consumers, leading to more decisive food recommendations. This assessment provides a conceptual development of the RBA methodology and is a robust basis on which to build upon.

Cryptosporidium Contamination and Attributed Risks in Yunlong Lake in Xuzhou, China

Swimming in surface water bodies (e.g., lakes, rivers) can expose the human body to substantial risk of infection by Cryptosporidium. These findings are from a one-year investigation on the occurrence and distribution of the protozoan parasite Cryptosporidium in Yunlong Lake, Xuzhou, China. Cryptosporidium oocysts were detected by immunofluorescence microscopy. From January to November of 2015, 180 samples (120 water samples and 60 sediment samples) were collected and analyzed. Among them, 42 (35%) water samples and 28 (47%) sediment samples tested positive for Cryptosporidium. The concentration of Cryptosporidium oocysts in the water samples was 0-8/10 L and 0-260/g in sediment samples. Results revealed that July was the highest risk period for both swimming and diving with an estimated probability of infection from swimming of greater than 18 per 10,000 swim sessions. It was concluded that swimming or diving in Yunlong Lake has a higher risk of Cryptosporidium infection than the acceptable risk level set by the United States Environmental Protection Agency. Thus, regular monitoring of water quality in recreation water bodies is strongly recommended.

Comparison of human and southern sea otter (Enhydra lutris nereis) health risks for infection with protozoa in nearshore waters

Cryptosporidium and Giardia spp. are waterborne, fecally-transmitted pathogens that cause economic loss due to gastroenteritis and beach closures. We applied quantitative microbial risk assessment (QMRA) to determine the health risks for humans and sea otters due to waterborne exposure of Cryptosporidium and Giardia spp. when swimming in three types of surface waters: river, stormwater and wastewater effluent during the wet and dry seasons in the central coast of California. This is the first application of QMRA to estimate both the probability of infection in Southern sea otters and the probability of illness in humans, using microbial source tracking (MST) as a variable. Children swimming close to stormwater discharges had an estimated Cryptosporidium-associated illness probability that exceeded the accepted U.S. EPA criteria (32 illnesses/1000 swimmers or 3.2%). Based on the assumption that sea otters are as susceptible as humans to Cryptosporidium infection, the infection probabilities were close to 2% and 16% when sea otters were swimming at the end of points of rivers and stormwater discharges, respectively. In the case of Giardia, infection probabilities of 11% and 23% were estimated for sea otters swimming at the end of point of wastewater discharges, assuming that sea otters are as susceptible as gerbils and humans, respectively. The results of this QMRA suggest that 1) humans and sea otters are at risk when swimming at outflow sites for rivers, stormwater and treated wastewater effluent; 2) reduced loads of viable protozoan cysts and oocysts in recreational water can lessen the probability of infection of humans and sea otters; and 3) the risk of infection of humans and sea otters can be reduced with the treatment of wastewater to decrease oocyst and cyst viability before effluent is released into the sea.

A quantitative risk assessment for metals in surface water following the application of biosolids to grassland

During episodic rainfall events, land application of treated municipal sludge ('biosolids') may give rise to surface runoff of metals, which may be potentially harmful to human health if not fully treated in a water treatment plant (WTP). This study used surface runoff water quality data generated from a field-scale study in which three types of biosolids (anaerobically digested (AD), lime stabilised (LS), and thermally dried (TD)) were spread on micro-plots of land and subjected to three rainfall events at time intervals of 24, 48 and 360h following application. Making the assumption that this water directly entered abstraction waters for a WTP without any grassed buffer zone being present, accounting for stream dilution, and modelling various performance scenarios within the WTP, the aim of this research was to conduct a human health risk assessment of metals (Cu, Ni, Pb, Zn, Cd and Cr), which may still be present in drinking water after the WTP. Different dose-response relationships were characterised for the different metals with reference to the lifetime average daily dose (LADD) and the Hazard Quotient (HQ). The results for the LADD show that child exposure concentrations were highest for Cu when the measured surface runoff concentrations from the LS biosolids treatment were used as input into the model. The results for the HQ showed that of all the scenarios considered, Cu had the highest HQ for children. However, values were below the threshold value of risk (HQ<0.01 - no existing risk). Under the conditions monitored, metal concentrations in the biosolids applied to grassland were not considered to result in a risk to human health in surface water systems.

Cryptosporidium Infection Risk: Results of New Dose-Response Modeling

Cryptosporidium human dose-response data from seven species/isolates are used to investigate six models of varying complexity that estimate infection probability as a function of dose. Previous models attempt to explicitly account for virulence differences among C. parvum isolates, using three or six species/isolates. Four (two new) models assume species/isolate differences are insignificant and three of these (all but exponential) allow for variable human susceptibility. These three human-focused models (fractional Poisson, exponential with immunity and beta-Poisson) are relatively simple yet fit the data significantly better than the more complex isolate-focused models. Among these three, the one-parameter fractional Poisson model is the simplest but assumes that all Cryptosporidium oocysts used in the studies were capable of initiating infection. The exponential with immunity model does not require such an assumption and includes the fractional Poisson as a special case. The fractional Poisson model is an upper bound of the exponential with immunity model and applies when all oocysts are capable of initiating infection. The beta Poisson model does not allow an immune human subpopulation; thus infection probability approaches 100% as dose becomes huge. All three of these models predict significantly (>10x) greater risk at the low doses that consumers might receive if exposed through drinking water or other environmental exposure (e.g., 72% vs. 4% infection probability for a one oocyst dose) than previously predicted. This new insight into Cryptosporidium risk suggests additional inactivation and removal via treatment may be needed to meet any specified risk target, such as a suggested 10^-4 annual risk of Cryptosporidium infection.

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

Quantitative microbial risk assessment (QMRA), the assessment of microbial risks when model inputs and estimated health impacts are explicitly quantified, is a valuable tool to support water safety plans (WSP). In this paper, research studies undertaken on the application of QMRA in drinking water systems were reviewed, highlighting their relevance for WSP. The important elements for practical implementation include: the data requirements to achieve sufficient certainty to support decision-making; level of expertise necessary to undertake the required analysis; and the accessibility of tools to support wider implementation, hence these aspects were the focus of the review. Recommendations to support the continued and growing application of QMRA to support risk management in the water sector are provided.

A pilot-scale study of Cryptosporidium-sized microsphere removals from swimming pools via sand filtration

Cryptosporidium species are the most common cause of gastrointestinal illness in treated recreational water venues. In order to protect public health during swimming, Cryptosporidium-sized microsphere removals by high-rate sand filtration with six coagulants were evaluated with a 5.5 m(3) pilot-scale swimming pool. A sand filter without coagulation removed 20-63% of Cryptosporidium-sized microspheres. Cryptosporidium-sized microsphere removals exceeded 98% by sand filtration with five of the six tested coagulants. Continuously feeding coagulants A, B, and F (i.e., organic polymers) led to coagulant accumulation in the system and decreased removals over time (<2 days). Coagulant E (polyaluminum chloride) consistently removed more than 90% of microspheres at 30 m/h while the removals dropped to approximately 50% at a filtration rate of 37 m/h. Coagulant C was a chitosan-based product that removed fewer microspheres compared with other products, <75%, under the studied conditions. Results indicated aluminum-based coagulants (coagulants D and E) had an overall performance advantage over the organic polymer based coagulants primarily in terms of their tendency not to accumulate in the water and cease to be effective at improving filter efficiency.

Public health significance of zoonotic Cryptosporidium species in wildlife: Critical insights into better drinking water management

Cryptosporidium is an enteric parasite that is transmitted via the faecal-oral route, water and food. Humans, wildlife and domestic livestock all potentially contribute Cryptosporidium to surface waters. Human encroachment into natural ecosystems has led to an increase in interactions between humans, domestic animals and wildlife populations. Increasing numbers of zoonotic diseases and spill over/back of zoonotic pathogens is a consequence of this anthropogenic disturbance. Drinking water catchments and water reservoir areas have been at the front line of this conflict as they can be easily contaminated by zoonotic waterborne pathogens. Therefore, the epidemiology of zoonotic species of Cryptosporidium in free-ranging and captive wildlife is of increasing importance. This review focuses on zoonotic Cryptosporidium species reported in global wildlife populations to date, and highlights their significance for public health and the water industry.

Integrated cryptosporidium assay to determine oocyst density, infectivity, and genotype for risk assessment of source and reuse water

Cryptosporidium continues to be problematic for the water industry, with risk assessments often indicating that treatment barriers may fail under extreme conditions. However, risk analyses have historically used oocyst densities and not considered either oocyst infectivity or species/genotype, which can result in an overestimation of risk if the oocysts are not human infective. We describe an integrated assay for determining oocyst density, infectivity, and genotype from a single-sample concentrate, an important advance that overcomes the need for processing multiple-grab samples or splitting sample concentrates for separate analyses. The assay incorporates an oocyst recovery control and is compatible with standard primary concentration techniques. Oocysts were purified from primary concentrates using immunomagnetic separation prior to processing by an infectivity assay. Plate-based cell culture was used to detect infectious foci, with a monolayer washing protocol developed to allow recovery and enumeration of oocysts. A simple DNA extraction protocol was developed to allow typing of any wells containing infectious Cryptosporidium. Water samples from a variety of source water and wastewater matrices, including a semirural catchment, wastewater, an aquifer recharge site, and storm water, were analyzed using the assay. Results demonstrate that the assay can reliably determine oocyst densities, infectivity, and genotype from single-grab samples for a variety of water matrices and emphasize the varying nature of Cryptosporidium risk extant throughout source waters and wastewaters. This assay should therefore enable a more comprehensive understanding of Cryptosporidium risk for different water sources, assisting in the selection of appropriate risk mitigation measures.

Quantitative microbial risk assessment of Cryptosporidium and Giardia in well water from a native community of Mexico

Cryptosporidium and Giardia are gastrointestinal disease-causing organisms transmitted by the fecal-oral route, zoonotic and prevalent in all socioeconomic segments with greater emphasis in rural communities. The goal of this study was to assess the risk of cryptosporidiosis and giardiasis of Potam dwellers consuming drinking water from communal well water. To achieve the goal, quantitative microbial risk assessment (QMRA) was carried out as follows: (a) identification of Cryptosporidium oocysts and Giardia cysts in well water samples by information collection rule method, (b) assessment of exposure to healthy Potam residents, (c) dose-response modelling, and (d) risk characterization using an exponential model. All well water samples tested were positive for Cryptosporidium and Giardia. The QMRA results indicate a mean of annual risks of 99:100 (0.99) for cryptosporidiosis and 1:1 (1.0) for giardiasis. The outcome of the present study may drive decision-makers to establish an educational and treatment program to reduce the incidence of parasite-borne intestinal infection in the Potam community, and to conduct risk analysis programs in other similar rural communities in Mexico.

Occurrence and potential health risk of Cryptosporidium and Giardia in the Three Gorges Reservoir, China

The Three Gorges Reservoir (TGR) is the biggest lake in the world and a major water source in China. There is no information about occurrence and impact of Cryptosporidium and Giardia on the aquatic ecosystem. 61 surface water samples from 23 monitoring sites and 5 treated effluent samples were collected and analyzed. Cryptosporidium oocysts and Giardia cysts were found, respectively, in 86.4% and 65.2% of a total of 66 water samples, with high concentrations in treated effluent. The mean percent recovery was 29.14% for oocysts and 34.86% for cysts. A seasonal pattern was observed, with positive samples for Cryptosporidium more frequent in flood period and positive samples for Giardia more frequent in impounding period. Counts of enterococci, fecal coliforms and total coliforms, and turbidity were significantly associated with Cryptosporidium concentration in backwater (water in a main river which is backed up by the Three Gorges Dam) areas of tributaries but not Giardia. High associations were also found between oocyst and cyst in backwater areas of tributaries and cities. The risks of infection and illness due to water consumption in four different exposure routes were estimated. The results showed that swimming in the TGR has the highest infection risk with 1.39 × 10(-3) per time (95% confidence interval (CI): 0.05-600.3 × 10(-5)) for Cryptosporidium and 2.08 × 10(-4) per time (95% CI: 0.05-878.87 × 10(-6)) for Giardia, while directly drinking unboiled tap water treated with the conventional process has the highest morbidity with 524.98 per 100,000 population per year (95% CI: 10.35-2040.26) for Cryptosporidium and 5.89 per 100,000 population per year (95% CI: 0.08-22.67) for Giardia. This study provides new useful information for drinking water plants, health care workers and managers to improve the safety of tap water and deduce the risk of surface water contamination in China.

Simulation model to predict the fate of ciprofloxacin in the environment after wastewater treatment

The extent hospital effluent contributes to antimicrobial presence in the environment and its impact on resistance dissemination remains unknown. To investigate the fate of the antimicrobial ciprofloxacin in hospital effluent a Monte Carlo simulation model was developed to model levels from hospital use to wastewater treatment plant (WWTP) effluent release, in addition to modeling resistance formation potential, hazard quotient (HQ) and swimmer exposure. The mean predicted concentration (PC) of ciprofloxacin in hospital effluent, urban effluent, WWTP effluent, sludge, soil and sea water was 579, 6.06, 2.59, 3.48, 0.006 and 0.15 mg/m(3), respectively. A parallel surveillance study confirmed levels of ciprofloxacin above or below the limit of detection. The model predicted levels would never exceed the ECOSAR toxicity value. The model predicted a 98% probability of ciprofloxacin exhibiting a HQ > 1 (low toxicity concern). The mean ciprofloxacin PC in WWTP effluent was less than the minimum inhibitory concentration (MIC). The probability of conditions in WWTP effluent being favorable for resistance at 20% and 80% of the MIC was 3% and 72%, respectively. In all instances, when the MIC was bound, the probability for resistance formation within soil and sea water was < 1%. The probability of a swimmer being exposed to a level of ciprofloxacin greater than the acceptable daily intake was negligible. The study concluded that release of hospital effluent into the environment may lead to concentrations of ciprofloxacin which are of low toxicity concern but may be conducive to resistance formation and allow for the dissemination of resistance.

The effect of conventional wastewater treatment on the levels of antimicrobial-resistant bacteria in effluent: a meta-analysis of current studies

Antimicrobial agents in the environment are a cause for concern. Antimicrobial drug residues and their metabolites reach the aquatic and terrestrial environment primarily through wastewater treatment plants (WWTP). In addition to the potential direct negative health and environmental effects, there is potential for the development of antimicrobial-resistant bacteria. Residue levels below the minimum inhibitory concentration for a bacterial species can be important in selection of resistance. There is uncertainty associated with resistance formation during WWTP processing. A meta-analysis study was carried out to analyse the effect of WWTP processing on the levels of antimicrobial-resistant bacteria within bacterial populations. An analysis of publications relating to multiple antimicrobial-resistant (MAR) bacteria (n = 61), single antimicrobial-resistant (SAR) E. coli (n = 81) and quinolone/fluoroquinolone-resistant (FR) bacteria (n = 19) was carried out. The odds-ratio (OR) of MAR (OR = 1.60, p < 0.01), SAR (OR = 1.33, p < 0.01) and FR (OR = 1.19, p < 0.01) bacteria was determined. The results infer that WWTP processing results in an increase in the proportion of resistant bacteria in effluent, even though the overall bacterial population may have reduced (i.e. a reduction in total bacterial numbers but an increase in the percentage of resistant bacteria). The results support the need for further research into the development of antimicrobial-resistant strains and possible selective pressures operating in WWTPs.

The burden of drinking water-associated cryptosporidiosis in China: the large contribution of the immunodeficient population identified by quantitative microbial risk assessment

A comprehensive quantitative microbial risk assessment (QMRA) of Cryptosporidium infection, considering pathogen removal efficiency, different exposure pathways and different susceptible subpopulations, was performed based on the result of a survey of source water from 66 waterworks in 33 major cities across China. The Cryptosporidium concentrations in source water were 0-6 oocysts/10 L, with a mean value of 0.7 oocysts/10 L. The annual diarrhea morbidity caused by Cryptosporidium in drinking water was estimated to be 2701 (95% confidence interval (CI): 138-9381) cases per 100,000 immunodeficient persons and 148 (95% CI: 1-603) cases per 100,000 immunocompetent persons, giving an overall rate of 149.0 (95% CI: 1.3-606.4) cases per 100,000 population. The cryptosporidiosis burden associated with drinking water treated with the conventional process was calculated to be 8.31 × 10(-6) (95% CI: 0.34-30.93 × 10(-6)) disability-adjusted life years (DALYs) per person per year, which was higher than the reference risk level suggested by the World Health Organization (WHO), but lower than that suggested by the United States Environmental Protection Agency (USEPA). Sixty-six percent of the total health burden due to cryptosporidiosis that occurred in the immunodeficient subpopulation, and 90% of the total DALYs was attributed to adults aged 15-59 years. The sensitivity analysis highlighted the great importance of stability of the treatment process and the importance of watershed protection. The results of this study will be useful in better evaluating and reducing the burden of Cryptosporidium infection.

Enteric protozoa in the developed world: a public health perspective

Several enteric protozoa cause severe morbidity and mortality in both humans and animals worldwide. In developed settings, enteric protozoa are often ignored as a cause of diarrheal illness due to better hygiene conditions, and as such, very little effort is used toward laboratory diagnosis. Although these protozoa contribute to the high burden of infectious diseases, estimates of their true prevalence are sometimes affected by the lack of sensitive diagnostic techniques to detect them in clinical and environmental specimens. Despite recent advances in the epidemiology, molecular biology, and treatment of protozoan illnesses, gaps in knowledge still exist, requiring further research. There is evidence that climate-related changes will contribute to their burden due to displacement of ecosystems and human and animal populations, increases in atmospheric temperature, flooding and other environmental conditions suitable for transmission, and the need for the reuse of alternative water sources to meet growing population needs. This review discusses the common enteric protozoa from a public health perspective, highlighting their epidemiology, modes of transmission, prevention, and control. It also discusses the potential impact of climate changes on their epidemiology and the issues surrounding waterborne transmission and suggests a multidisciplinary approach to their prevention and control.

Risk assessment of Giardia in rivers of southern China based on continuous monitoring

The occurrence and risks of Giardia in China have been unclear to date, which has made it difficult to properly manage source water as well as to create reasonable drinking water standards. The levels of Giardia in river networks of several cities in Zhejiang Province, China were found to be in the range of 0-5 oocysts/10 L in the rainy season in 2008. The mortality due to Giardia infection for people in this region was calculated to be from 0 to 1.95 x 10(-8) persons using a conditional probability equation. Based on multiple unboiled water intake routes, the disability-adjusted life years (DALYs) due to Giardia infection for people who consumed conventionally treated water was 0.625 (95% CI: 0.137-2.05) per 10(5) persons, with the symptom of hospitalization making the highest contribution to total DALYs (0.56 per 10(5) persons; 95% CI: 0.122-1.84). The DALYs decreased to 0.425 (95% CI: 0.137-2.05) per 10(5) persons per year for those consuming water treated with advanced technology. These values were lower than the acceptable risk (1.97 x 10(-5) DALYs per year). This study revealed the risk of Giardia infection to the people in river networks of Zhejiang Province for the first time, and provides a method to evaluate the risk of Giardia infection. The results are useful for the modification of drinking water quality standards based on cost-benefit analysis.

Quantitative health risk assessment of Cryptosporidium in rivers of southern China based on continuous monitoring

The concentrations of Cryptosporidium in the source water of several cities of Zhejiang Province, China were determined to be in the range of 0-17 oocysts/10 L in the rainy season in 2008, with a mean value of 7 oocysts/10 L. Based on the investigation data, comprehensive risk assessment of Cryptosporidium infection was performed by considering different water intake routes as well as water consumption. Intakes of unboiled tapwater (including drinking and tooth-brushing and food and dish washing) and source water (through swimming in rivers) were estimated to be 2.59-25.9 and 0.32-0.74 L/year-person, respectively. The mortality due to Cryptosporidium infection for people in this region, excluding HIV-infected patients, was calculated as 0-0.0146 per 10(5) persons using a conditional probability formula. Disability-adjusted life years (DALYs) were used to quantify the risk of Cryptosporidium infection, for which uncertainty was analyzed. For people who consumed conventionally treated water, the DALYs due to Cryptosporidium infection were 6.51 per 10(5) (95% CI: 2.16 × 10(-5)-22.35 × 10(-5)) persons, which were higher than a risk judged acceptable by some (1.97 × 10(-5) DALYs per year), and the risk for those consuming ozone-treated water became 0.0689 × 10(-5) DALYs per year. The major risk of infection resulted from swimming in the river. This study provides a method to establish the risk of Cryptosporidium infection and optimize the scheme for reducing the risk effectively, which is useful for the modification of water quality standards based on cost utility analysis given use of DALYs.

Cryptosporidium spp. and Giardia duodenalis in two areas of Galicia (NW Spain)

The aim of the present study was to investigate the environmental dispersal of Cryptosporidium spp. and Giardia duodenalis in two distinct areas (coastal and inland) in Galicia (NW Spain). Faecal samples were collected from healthy asymptomatic domestic (cows and sheep) and wild animals (deer and wild boars) in the selected areas. In each of the selected areas, samples of untreated water (influent) and of treated water (final effluent) were collected from each of the 12 drinking water treatments plants (DWTPs) and 12 wastewater treatment plants (WTPs) under study. Analysis of a single sample from each of the 635 (coastal) and 851 (inland) domestic and wild animals selected at random revealed that the prevalences of cryptosporidiosis and giardiosis in coastal area were 9.2% and 15.9% respectively, and in inland area, 13.7% and 26.7% respectively. In the coastal area, Cryptosporidium spp. oocysts were detected in influent and effluent samples from 2/12 (16.6%) DWTPs and 8/12 (66.6%) WTPs, while G. duodenalis cysts were detected in influent and effluent samples from 3/12 (25.0%) DWTPs and 12/12 (100%) WTPs. The concentrations were notably higher in WTPs; the mean parasite concentrations in the final treated effluent were 10 oocysts per litre and 137.8 cysts per litre for Cryptosporidium and Giardia, respectively. The mean concentration of G. duodenalis cysts per litre was significantly higher (P<0.05) than the mean concentration of Cryptosporidium spp. oocysts per litre in both the influent and the effluent samples from all the treatment plants. In the coastal area, C. parvum, C. hominis and G. duodenalis assemblages A (I and II) and E were most repeatedly detected. In the inland area, C. parvum, C. andersoni and G. duodenalis assemblages A (I and II), B and E were most frequently identified.

QMRA and decision-making: are we handling measurement errors associated with pathogen concentration data correctly?

Knowledge of the variability in pathogen or indicator concentrations over time at a particular location (e.g. in drinking water sources) is essential in implementation of concentration-based regulations and in quantitative microbial risk assessment. Microbial enumeration methods, however, are known to yield highly variable counts (even among replicates) and some methods are prone to substantial losses (i.e. only a fraction of the target microorganisms in a sample are observed). Consequently, estimated microorganism concentrations may be biased and only a fraction of the variability that is observed in temporally distributed concentration estimates is due to variability in concentration itself. These issues have often been ignored in the past, and approaches to integrate knowledge about the measurement error associated with enumeration methods into decisions have not been standardized. Here, an existing model that describes variability in microorganism counts as a function of sample volume and the analytical recovery of the enumeration method is expanded to include temporal concentration variability and sample-specific recovery information. This model is used to demonstrate that microorganism counts and analytical recovery are not independent (as has often been assumed), even if the correlation is obscured by other sources of variability in the data. It is also used as an experimental design tool to evaluate strategies that may yield more accurate concentration estimates. Finally, the model is implemented in a Bayesian framework (with a Gibbs sampling algorithm) to quantify temporal concentration variability with appropriate consideration of measurement errors in the data and the analytical recovery of the enumeration method. We demonstrate by simulation that this statistical approach facilitates risk analyses that appropriately model variability in microorganism concentrations given the available data and that it enables decisions based on quantitative measures of uncertainty.

Cryptosporidium and Giardia detection in water bodies of Galicia, Spain

The objective of this study was to determine the mean concentration (per litre) of Cryptosporidium oocysts and Giardia cysts in recreational river areas (n = 28), drinking water treatments plants (DWTPs; n = 52) and wastewater treatment plants (WWTPs; n = 50) in Galicia (NW Spain). Water samples from rivers and from the influent (50-100 l) and the treated effluent (100 l) of the water plants were filtered using Filta-Max filters (IDEXX Laboratories, Inc., Westbrook, ME, USA). A total of 232 samples were processed and the (oo)cysts were concentrated, clarified by IMS and then detected by IFAT. The viability was determined by applying fluorogenic vital dye (PI). In the recreational areas, infective forms of Cryptosporidium and Giardia were detected in 16 (57.1%; 1-60 oocysts per litre) and 17 (60.7%; 1-160 cysts per litre) samples, respectively. In the water flowing into the water treatment plants, oocysts were detected in 21 DWTPs (40.4%; 1-13 oocysts per litre) and cysts were observed in 22 DWTPs (42.3%; 1-7 cysts per litre). In the effluents from the treatment plants, Cryptosporidium oocysts and Giardia cysts were identified in 17 DWTPs (32.7%; 1-4 oocysts per litre) and in 19 DWTPs (36.5%; 1-5 cysts per litre), respectively. The highest concentrations of (oo)cysts were found in the WWTPs; specifically, oocysts were detected in 29 (58.0%; 1-80 oocysts per litre) and cysts in 49 (98.0%; 2-14.400 cysts per litre) WWTP effluents. Cryptosporidium and Giardia were detected in 32 (64.0%; 1-120 oocysts per litre) and 48 (96.0%; 2-6.000 cysts per litre) WWTP effluents, respectively. The percentage viability of the (oo)cysts ranged between 90.0% and 95.0%. In all samples analysed. Moreover, it was found that the effluents from coastal WWTPs were discharged directly into the sea, while inland WWTPs were discharged directly into rivers. The concentrations of both enteropathogens detected in effluents from WWTPs therefore represent a significant risk to human and animal health. These results demonstrate the wide distribution of Cryptosporidium and Giardia in the environment, the ineffectiveness of treatments in DWTPs and WWTPs in reducing/inactivating both protozoa and the need to monitor the presence, viability and infectivity of Cryptosporidium and Giardia in water bodies. In conclusion, the findings suggest the need for better monitoring of water quality and identification of sources of contamination.