Quantitative microbial risk assessment of outdoor aerosolized pathogens in cities with poor sanitation

Evaluating the risk of Clostridioides difficile infection from toilet flushing: a quantitative microbial risk assessment and implications for infection control

BACKGROUND

Despite stringent infection control measures, Clostridioides difficile infection (CDI) remains a challenge in healthcare settings, partly due to overlooked transmission vectors such as toilet plume bioaerosols.

AIM

To systematically quantify the risks associated with CDI transmission via toilet flushing and provide critical insights to inform CDI preventive strategies.

METHODS

Impaction sampling was used to quantify airborne C. difficile post-flush and high-contact surfaces were swabbed to assess contamination levels, in a controlled toilet environment. A quantitative microbial risk assessment (QMRA) approach was then used to estimate the risk to subsequent users from contamination by a previously colonized individual.

FINDINGS

A single flush can release C. difficile into the air, with bioaerosol concentrations up to 29.50 ± 10.52 cfu/m3 and deposit about 8-11 cfu on immediate surfaces. Despite a 4.4 log reduction in bacterial concentration within the toilet bowl post-flush, bacteria persist on its inner walls. Relative humidity increases by approximately 31.28% within the first 10 min post-flush, potentially enhancing the viability and transmission of aerosolized C. difficile. The flush button contact and inhalation-followed-by-ingestion in frequent-use hospital settings present the highest risks and exceed US EPA and WHO acceptable infection risk thresholds.

CONCLUSION

The findings of this study necessitate a review of current toilet designs, public health policies and facility management practices to mitigate the overlooked risks of CDI transmission through toilet plume bioaerosols in healthcare settings. Additionally, this study lays a foundation for developing evidence-based interventions aimed at achieving substantial behavioural and infrastructural changes in infection control practices.

Occurrence, predictive models and potential health risk assessment of viable but non-culturable (VBNC) pathogens in drinking water

Viable but non-culturable (VBNC) pathogens are prevalent in drinking water systems and can resuscitate under favorable conditions, thereby posing significant public health risks. This study investigated the occurrence of VBNC Escherichia coli and Pseudomonas aeruginosa in source water, tap water, and potable water in eastern China, using propidium monoazide-quantitative PCR and culture-based methods. Multiple linear regression (MLR) and artificial neural network (ANN) models were developed based on conventional water quality indicators to predict VBNC pathogen concentrations. The results indicated that drinking water treatment plants effectively reduced VBNC pathogens by 1-3 log units, however, concentrations ranging from 100 to 102 CFU/100 mL remained in tap and potable water, with detection rates between 83.33% and 100%. Furthermore, potable water contained a higher concentration of VBNC pathogens than tap water, suggesting a potential risk of microbial leakage from water dispensers. The constructed ANN models outperformed than MLR models, with R values greater than 0.8, indicating a strong correlation between measured values and model predictions for VBNC pathogens. ANN models also demonstrated superior accuracy than MLR models in predicting VBNC pathogens across different type of drinking water, achieving accuracies of 88.89% for Escherichia coli and 77.78% for Pseudomonas aeruginosa. The QMRA revealed that annual infection risks and disease burdens from VBNC pathogens in potable water were greater than those in tap water, with both exceeding acceptable safety thresholds. This study emphasizes that the risks posed by VBNC pathogens deserve attention and model predictions provide critical evidence for health risk identification.

Assessing microbial risks of Escherichia coli: A spatial and temporal study of virulence and resistance genes in surface water in resource-limited regions

Environmental microbial pollution can potentially cause illnesses and deaths among human populations. Environmental factors such as geomorphology, land use, human activities, and seasonality could influence pathogen dissemination. This study performed a space-temporal analysis of Escherichia coli concentrations, virulence (eaeA, bfpA, stx2, aatA, and st), and resistance (tetA, blaTEM, blaOXA, Intl-1, Intl-2, sul-1, and sul-2) genes in surface water within the Virilla sub-watershed, Costa Rica. The research employs microbiological, geostatistical, and quantitative microbial risk assessment (QMRA) techniques to evaluate the health risks associated with diarrheagenic E. coli. Samples collected monthly over a year were analyzed for fecal coliforms, E. coli, Enterococcus faecalis, physicochemical parameters, and the presence of virulence and resistance genes. The geographically weighted regression model identified significant associations between the virulence and resistance genes presence and environmental factors influence such as land use, slope, altitude, and seasonal changes. The results show that urban and grazing land use significantly influence the presence of resistance genes, while human fecal pollution is associated with higher concentrations of virulence genes. Seasonal variations showed that wet seasons contributed to increased gene presence (number of positive samples) and diversity (variety of virulence and resistance genes) compared with dry season. The QMRA results indicated that the total health disease burden was higher than the benchmark for drinking water recommended by WHO (1.00 × 10-6 DALY - Disability-Adjusted Life Years - per person per year) by between one and four magnitudes orders, particularly in regions with urban and grazing land use, human fecal pollution class, and lower altitudes. This study highlights the relevance of integrating environmental and microbial data to enhance water quality management and public health strategies in resource-limited regions. It underscores the need for targeted interventions, such as improved wastewater treatment and establishing buffer zones, to mitigate the risks associated with microbial pollution in surface waters.

Beyond water and soil: Air emerges as a major reservoir of human pathogens

Assessing the risk of human pathogens in the environment is crucial for controlling the spread of diseases and safeguarding human health. However, conducting a thorough assessment of low-abundance pathogens in highly complex environmental microbial communities remains challenging. This study compiled a comprehensive catalog of 247 human-pathogenic bacterial taxa from global biosafety agencies and identified more than 78 million genome-specific markers (GSMs) from their 17,470 sequenced genomes. Subsequently, we analyzed these pathogens' types, abundance, and diversity within 474 shotgun metagenomic sequences obtained from diverse environmental sources. The results revealed that among the four habitats studied (air, water, soil, and sediment), the detection rate, diversity, and abundance of detectable pathogens in the air all exceeded those in the other three habitats. Air, sediment, and water environments exhibited identical dominant taxa, indicating that these human pathogens may have unique environmental vectors for their transmission or survival. Furthermore, we observed the impact of human activities on the environmental risk posed by these pathogens, where greater amounts of human activities significantly increased the abundance of human pathogenic bacteria, especially in water and air. These findings have remarkable implications for the environmental risk assessment of human pathogens, providing valuable insights into their presence and distribution across different habitats.

Evaluation of pathogen spread risk from excavated landfill

Landfill is a huge pathogen reservoir and needs special attention. Herein, the distribution and spread risk of pathogen were assessed in excavated landfill scenario. The results show that landfill excavation will greatly increase the risk of environmental microbial contamination. The highest total concentration of culturable bacteria among landfill refuse, topsoil and plant leaves was found to be as high as 1010 CFU g-1. Total coliforms, Hemolytic bacteria, Staphylococcus aureus, Salmonella, Enterococci, and Fecal coliforms were detected in the landfill surrounding environment. Notably, pathogens were more likely to adhere to plant leaves, making it an important source of secondary pathogens. The culturable bacteria concentration in the air samples differed with the landfill zone with different operation status, and the highest culturable bacteria concentration was found in the excavated area of the landfill (3.3 × 104 CFU m-3), which was the main source of bioaerosol release. The distribution of bioaerosols in the downwind outside of the landfill showed a tendency of increasing and then decreasing, and the highest concentration of bioaerosols outside of the landfill (6.56 × 104 CFU m-3) was significantly higher than that in the excavated area of the landfill. The risk of respiratory inhalation was the main pathway leading to infection, whereas the HQin (population inhalation hazardous quotient) at 500 m downwind the excavation landfill was still higher than 1, indicating that the neighboring residents were exposed to airborne microbial pollutants. The results of the study provide evidence for bioaerosols control protective measures taken to reduce health risk from the excavated landfill.

Molecular insights into microbial transformation of bioaerosol-derived dissolved organic matter discharged from wastewater treatment plant

Wastewater treatment plants (WWTP) are important sources of aerosol-derived dissolved organic matter (ADOM) which may threaten human health via the respiratory system. In this study, aerosols were sampled from a typical WWTP to explore the chemical molecular diversity, molecular ecological network, and potential toxicities of the ADOM in the aerosols. The high fluorescence index (>1.9) and biological index (0.66-1.17) indicated the strong autogenous microbial source characteristics of the ADOM in the WWTP. DOM and microbes in the wastewater were aerosolized due to strong agitation and bubbling in the treatment processes, and contributed to 74 % and 75 %, respectively, of the ADOM and microbes in the aerosols. The ADOM was mainly composed of CHO and CHOS accounting for 35 % and 29 % of the total number of molecules, respectively, with lignin-like (69 %) as the major constituent. 49 % of the ADOM transformations were thermodynamically limited, and intragroup transformations were easier than intergroup transformations. Bacteria in the aerosols involved in ADOM transformations exhibited both cooperative and divergent behaviors and tended to transform carbohydrate-like and amino sugar/protein-like into recalcitrant lignin-like. The microbial compositions were affected by atmosphere temperature and humidity indirectly by modulating the properties of ADOM. Tannin-like, lignin-like, and unsaturated hydrocarbon-like molecules in the ADOM were primary toxicity contributors, facilitating the expression of inflammatory factors IL-β (2.2-5.4 folds), TNF-α (3.5-7.0 folds), and IL-6 (3.5-11.2 folds), respectively.

Viral-Bacterial Interactions That Impact Viral Thermostability and Transmission

Enteric viruses are significant human pathogens that commonly cause foodborne illnesses worldwide. These viruses initiate infection in the gastrointestinal tract, home to a diverse population of intestinal bacteria. In a novel paradigm, data indicate that enteric viruses utilize intestinal bacteria to promote viral replication and pathogenesis. While mechanisms underlying these observations are not fully understood, data suggest that some enteric viruses bind directly to bacteria, stabilizing the virion to retain infectivity. Here, we discuss the current knowledge of these viral-bacterial interactions and examine the impact of these interactions on viral transmission.

Antibiotic Resistance Genes in Aerosols: Baseline from Kuwait

Antimicrobial resistance (AMR) is one of the biggest threats to human health worldwide. The World Health Organization (WHO, Geneva, Switzerland) has launched the "One-Health" approach, which encourages assessment of antibiotic-resistant genes (ARGs) within environments shared by human-animals-plants-microbes to constrain and alleviate the development of AMR. Aerosols as a medium to disseminate ARGs, have received minimal attention. In the present study, we investigated the distribution and abundance of ARGs in indoor and outdoor aerosols collected from an urban location in Kuwait and the interior of three hospitals. The high throughput quantitative polymerase chain reaction (HT-qPCR) approach was used for this purpose. The results demonstrate the presence of aminoglycoside, beta-lactam, fluoroquinolone, tetracycline, macrolide-lincosamide-streptogramin B (MLSB), multidrug-resistant (MDR) and vancomycin-resistant genes in the aerosols. The most dominant drug class was beta-lactam and the genes were IMP-2-group (0.85), Per-2 group (0.65), OXA-54 (0.57), QnrS (0.50) and OXA-55 (0.55) in the urban non-clinical settings. The indoor aerosols possessed a richer diversity (Observed, Chao1, Shannon's and Pielou's evenness) of ARGs compared to the outdoors. Seasonal variations (autumn vs. winter) in relative abundances and types of ARGs were also recorded (R² of 0.132 at p < 0.08). The presence of ARGs was found in both the inhalable (2.1 µm, 1.1 µm, 0.7 µm and < 0.3 µm) and respirable (>9.0 µm, 5.8 µm, 4.7 µm and 3.3 µm) size fractions within hospital aerosols. All the ARGs are of pathogenic bacterial origin and are hosted by pathogenic forms. The findings present baseline data and underpin the need for detailed investigations looking at aerosol as a vehicle for ARG dissemination among human and non-human terrestrial biota.

Three Experimental Common High-Risk Procedures: Emission Characteristics Identification and Source Intensity Estimation in Biosafety Laboratory

Biosafety laboratory is an important place to study high-risk microbes. In biosafety laboratories, with the outbreak of infectious diseases such as COVID-19, experimental activities have become increasingly frequent, and the risk of exposure to bioaerosols has increased. To explore the exposure risk of biosafety laboratories, the intensity and emission characteristics of laboratory risk factors were investigated. In this study, high-risk microbe samples were substituted with Serratia marcescens as the model bacteria. The resulting concentration and particle size segregation of the bioaerosol produced by three experimental procedures (spill, injection, and sample drop) were monitored, and the emission sources' intensity were quantitatively analyzed. The results showed that the aerosol concentration produced by injection and sample drop was 103 CFU/m3, and that by sample spill was 102 CFU/m3. The particle size of bioaerosol is mainly segregated in the range of 3.3-4.7 μm. There are significant differences in the influence of risk factors on source intensity. The intensity of sample spill, injection, and sample drop source is 3.6 CFU/s, 78.2 CFU/s, and 664 CFU/s. This study could provide suggestions for risk assessment of experimental operation procedures and experimental personnel protection.

Toilet plume bioaerosols in health care and hospitality settings: A systematic review

BACKGROUND

The spread of some respiratory and gastro-intestinal infections has been linked to the exposure to infectious bioaerosols released after toilet flushing. This represents a health hazard and infection risk for immunocompromised patients, health workers and the public, particularly within the health care and hospitality settings. This systematic review provides current knowledge and identifies gaps in the evidence regarding toilet plume bioaerosols and the potential contributory role in spreading infections in health care and hospitality settings.

METHODS

The PRISMA guidelines were used. Searches were run in PubMed, Scopus, and Google Scholar from 1950 to 30th June 2021. Searches of global and regional reports and updates from relevant international and governmental organizations were also conducted.

RESULTS AND CONCLUSION

The search yielded 712 results, and 37 studies were finally selected for this review. There is a lack of national and international bioaerosol sampling and exposure standards for health care and hospitality settings. Toilet plume bioaerosols are complex in nature, thus, measured bioaerosol concentrations in these settings depend on many variables and may differ for every pathogen responsible for a particular infectious disease. The contact and airborne transmission risks posed by toilet plume bioaerosols also remain unquantified. They are an important pathway that can increase the exposure to enteric and airborne pathogens. Hence, quantitative risk assessment and related research are needed to investigate these transmission risks.

Distribution characteristics and potential risks of bacterial aerosol in waste transfer station

The waste transfer station (WTS) is an important link in the transfer of municipal solid waste (MSW) between the community and disposal terminals. While WTSs facilitate waste collection in communities, odorous gases and bioaerosols can escape from them, thereby negatively affecting their surroundings. In this study, the concentration, particle size distribution, pathogen population, and health risks of bioaerosols were analyzed at different locations in a transfer station. The results showed that the highest viable bacterial aerosol concentration was 10,353 ± 3701 CFU/m³, which was at 5 m from the disposal site. Fifty-three bacterial species, including pathogens, were detected. Of these, 39 were human pathogenic bacteria directly originating from the WTS. Furthermore, health risk assessments indicated unacceptable levels of non-carcinogenic risk for operational workers caused by bacterial aerosols of the WTS work area. In addition, bacterial aerosols may pose a severe health risk to children within a 15 m area of the WTS. The results of this study provide a scientific basis to control and reduce the risk associated with bioaerosol exposure in solid WTSs.

An application for relating Legionella shower water monitoring results to estimated health outcomes

Exposure models are useful tools for relating environmental monitoring data to expected health outcomes. The objective of this study was to (1) compare two Legionella shower exposure models, and (2) develop a risk calculator tool for relating environmental monitoring data to estimated Legionella infection risks and Legionnaires' Disease (LD) illness risks. Legionella infection risks for a single shower event were compared using two shower Legionella exposure models. These models varied in their description of partitioning of Legionella in aerosols and aerosol deposition in the lung, where Model 1 had larger and fewer aerosol ranges than Model 2. Model 2 described conventional vs. water efficient showers separately, while Model 1 described exposure for an unspecified shower type (did not describe it as conventional or water efficient). A Monte Carlo approach was used to account for variability and uncertainty in these aerosolization and deposition parameters, Legionella concentrations, and the dose-response parameter. Methods for relating infection risks to illness risks accounting for demographic differences were used to inform the risk calculator web application ("app"). Model 2 consistently estimated higher infection risks than Model 1 for the same Legionella concentration in water and estimated deposited doses with less variability. For a 7.8-min shower with a Legionella concentration of 0.1 CFU/mL, the average infection risks estimated using Model 2 were 4.8 × 10^-6 (SD=3.0 × 10^-6) (conventional shower) and 2.3 × 10^-6 (SD=1.7 × 10^-6) (water efficient). Average infection risk estimated by Model 1 was 1.1 × 10^-6 (SD=9.7 × 10^-7). Model 2 was used for app development due to more conservative risk estimates and less variability in estimated dose. While multiple Legionella shower models are available for quantitative microbial risk assessments (QMRAs), they may yield notably different infection risks for the same environmental microbial concentration. Model comparisons will inform decisions regarding their integration with risk assessment tools. The development of risk calculator tools for relating environmental microbiology data to infection risks will increase the impact of exposure models for informing water treatment decisions and achieving risk targets.