Efficacy of water treatment processes and endemic gastrointestinal illness - A multi-city study in Sweden

The complex association between drinking water consumption and endemic gastrointestinal illness as shown by Swedish cohort studies

It is well known that municipal drinking water may be the cause of gastrointestinal illness (GII) outbreaks, but it is still unclear to what extent drinking water contributes to endemic GII. To explore this, we conducted a prospective cohort study among 6,955 adults in five municipalities in Sweden, collecting monthly GII episodes and mean daily cold drinking water consumption through SMS (Short Message Service). When the association between drinking water consumption and GII (all symptoms) and acute gastrointestinal illness (AGI, vomiting and/or three loose stools during a 24-h period) were assessed, there were indications that the association departed from linearity, following a unimodal shape. Among consumers in surface water areas, the highest risk of GII and AGI was generally seen among the average consumers, while the opposite was seen among groundwater consumers. The association however also seemed to be affected by neighbouring communities. The results of the study indicate that there is indeed an association between drinking water consumption and endemic GII, but the nature of this association is complex and likely affected by multiple factors, for example, water source type in the home and degree of exposure to drinking water from additional sources.

Intensified inactivation of model and environmental bacteria by an atmospheric-pressure air-liquid discharge plasma compared with chlorination

Water-borne pathogenic bacteria are always the top priority to be removed through disinfection process in water treatment due to their threat to human health. It was necessary to develop novel disinfection methods since the conventional chlorine disinfection was inefficient in inactivating chlorine-resistant bacteria, inducing the viable but non-culturable (VBNC) bacteria and forming disinfection by-products (DBPs). In this study, the inactivation of four model strains including Gram-negative (G^-), Gram-positive (G⁺) and environmental samples by atmospheric-pressure air-liquid discharge plasma (ALDP) was assessed systematically. The results showed that ALDP was superior in inactivating all of the samples compared with chlorination. During 10 min ALDP treatment, the G^- bacteria were completely inactivated, and the G⁺ one was inactivated by more than 4.61 logs. The inactivation of bacteria from a campus lake and a wastewater treatment plant effluent exceeded 99.82% and 97.78%, respectively. For G^- bacteria, ALDP resulted in a much lower (10²∼10³ times) levels of VBNC cells than chlorination. ALDP could effectively remove the chlorine-resistant bacteria. More than 96.41% of the intracellular DNA and 99.99% of the extracellular DNA were removed, whereas it was only 56.35% and 12.82% for chlorination. ALDP had a stronger ability to destroy cell structure than chlorination, presumably due to the existence of ROS (·OH, ¹O₂ and O₂^-). GC-MS analysis showed that ALDP produced less DBPs than chlorination. These findings provided new insights for the application of discharge plasma in water disinfection, which could be complemental or alternative to the conventional disinfection methods.

Comparison of Skimmed Milk and Lanthanum Flocculation for Concentration of Pathogenic Viruses in Water

Concentration of viruses in water is necessary for detection and quantification of the viruses present, in order to evaluate microbiological barriers in water treatment plants and detect pathogenic viruses during waterborne outbreaks, but there is currently no standardised procedure. In this study, we implemented a previously described fast and simple lanthanum-based protocol for concentration of norovirus genogroup I (GI), genogroup II (GII) and hepatitis A virus (HAV) in drinking and surface water. We compared the results with those of a widely used skimmed milk flocculation method, followed by nucleic acid extraction and RT-qPCR detection. Three seeding levels, with intended concentrations 5 × 10³, 5 × 10⁴ and 5 × 10⁵ genome copies/10 L, were added to drinking water or surface water. All seed levels were detected with both flocculation methods. Samples extracted with skimmed milk flocculation had on average 1.82, 1.86 and 1.38 times higher measured concentration of norovirus GI, GII and HAV, respectively, than those extracted with lanthanum flocculation, across all seeding levels and water types tested. Mengovirus was used as a positive process control. Mengovirus recovery was higher for skimmed milk (40.7% in drinking water, 26.0% in surface water) than for lanthanum flocculation (24.4% in drinking water, 9.7% in surface water). Together, this indicates that skimmed milk flocculation provides higher viral recovery than lanthanum flocculation. However, lanthanum-based flocculation can be performed much faster than skimmed milk flocculation (1.5 h versus 16 h flocculation time) and thus could be a good alternative for rapid monitoring of viruses in water.

Hazardous cyanobacteria integrity response to velocity gradient and powdered activated carbon in water treatment plants

Although some studies have investigated the impact caused by chemicals used on water treatment (coagulants and oxidants) on cyanobacteria integrity, the isolated effect of shear stress during coagulation is still not fully understood. This study evaluated the impact of different velocity gradients, mixing times, and the addition of powdered activated carbon (PAC) on the integrity of Microcystis aeruginosa, Raphidiopsis raciborskii, and Dolichospermum circinale, known producers of toxin and taste and odor (T&O) compounds. No association was found between R. raciborskii cell lysis and velocity gradient, with or without PAC, demonstrating the high resilience of this taxon to shear stress. In contrast, an association was found for M. aeruginosa at the highest velocity gradient evaluated (1000 s^-1) and for D. circinale above the lowest velocity gradient studied (600 s^-1). After PAC addition, there was a reduction in the chances of finding M. aeruginosa intact cells above velocity gradient 800 s^-1 at 45 s, while D. circinale show cell lysis in all the scenarios expect at 600 s^-1 and 10 s of agitation. The additional impact of PAC on cell lysis may lead to more release of metabolites and shows the need to adjust the hydraulic conditions in the rapid mixing stage, especially when more "fragile" cyanobacteria are present. Neither cyanobacterial cell size nor morphology was shown to be relevant to shear stress sensitivity, indicating that cell wall composition might have been an important factor in controlling cell lysis.

Endemic gastrointestinal illness and change in raw water source and drinking water production - A population-based prospective study

There are indications that drinking water may contribute to endemic gastrointestinal illness (GII) even when the drinking water quality meets current standards, but the knowledge is limited. In this population-based prospective study, we assessed if changes in municipal drinking water production affected the GII incidence, by collecting self-reported GII episodes among the population in two municipalities during calendar time-specific inter-annual periods. About 2600 adults in central Sweden and 2600 adults (including 700 households with children aged 0-9 years) in Southwest Sweden, were followed during a baseline and a follow-up period in 2012-2016. Monthly reports of episodes and symptoms of GII were collected by SMS. The following drinking water related changes were assessed: Change 1 (adults); a municipality with a groundwater treatment, changed to a different groundwater source with UV treatment; Change 2 (adults); a municipality with a surface water treatment changed to a groundwater source with UV treatment; and Change 3a (adults) and 3b (children): a municipality with a surface water treatment changed to a new surface water source, having a treatment with a higher pathogen reduction. We observed no evidence that changes in raw water source and/or improved pathogen removal in the drinking water treatment affected the risk of GII among adults. Among children aged 0-9 years participating in Change 3b, we observed a 24% relative risk reduction in GII incidence. These results suggest that improved water treatment may reduce the disease burden of GII in children even in settings in which water treatment efficacy meets current quality standards.

Time series study of weather, water quality, and acute gastroenteritis at Water Safety Plan implementation sites in France and Spain

Water Safety Plans (WSPs), recommended by the World Health Organization since 2004, can help drinking water suppliers to proactively identify potential risks and implement preventive barriers that improve safety. Few studies have investigated long-term impacts of WSPs, such as changes in drinking water quality or public health; however, some evidence from high-income countries associates WSP implementation with a reduction in diarrheal disease. To validate the previously observed linkages between WSPs and health outcomes, this time series study examined site-specific relationships between water-related exposures and acute gastroenteritis rates at three locations in France and Spain, including the role of WSP status. Relationships between control or exposure variables and health outcomes were tested using Poisson regression within generalized additive models. Controls included suspected temporal trends in disease reporting. Exposures included temperature, precipitation, raw water quality, and finished water quality (e.g., turbidity, free chlorine). In France, daily acute gastroenteritis cases were tracked using prescription reimbursements; Spanish data aggregated monthly acute gastroenteritis hospital visits. The models identified several significant relationships between indicators of exposure and acute gastroenteritis. Lag times of 6-9 days (including transit time) were most relevant for hydrological indicators (related to precipitation, runoff, and flow) at the two French sites, indicative of viral pathogens. Flush events (defined as surface runoff after a two-week antecedent dry period) linked to nonpoint source pollution were associated with a 10% increase in acute gastroenteritis rates at one location supplied by surface water. Acute gastroenteritis rates were positively associated with elevated turbidity average or maximum values in finished water at locations supplied by both surface and groundwater, by about 4% per 1-NTU increase in the two-week moving average of daily maxima or about 10% per 0.1 NTU increase in the prior month's average value. In some cases, risk appeared to be mitigated by WSP-related treatment interventions. Our results suggest drinking water exposure is associated with some potentially preventable gastrointestinal illness risk in high-income regions.

Improved Detection of Norovirus and Hepatitis A Virus in Surface Water by Applying Pre-PCR Processing

Quantitative reverse transcriptase polymerase chain reaction (RT-qPCR) detection of waterborne RNA viruses generally requires concentration of large water volumes due to low virus levels. A common approach is to use dead-end ultrafiltration followed by precipitation with polyethylene glycol. However, this procedure often leads to the co-concentration of PCR inhibitors that impairs the limit of detection and causes false-negative results. Here, we applied the concept of pre-PCR processing to optimize RT-qPCR detection of norovirus genogroup I (GI), genogroup II (GII), and hepatitis A virus (HAV) in challenging water matrices. The RT-qPCR assay was improved by screening for an inhibitor-tolerant master mix and modifying the primers with twisted intercalating nucleic acid molecules. Additionally, a modified protocol based on chaotropic lysis buffer and magnetic silica bead nucleic acid extraction was developed for complex water matrices. A validation of the modified extraction protocol on surface and drinking waters was performed. At least a 26-fold improvement was seen in the most complex surface water studied. The modified protocol resulted in average recoveries of 33, 13, 8, and 4% for mengovirus, norovirus GI, GII, and HAV, respectively. The modified protocol also improved the limit of detection for norovirus GI and HAV. RT-qPCR inhibition with C _q shifts of 1.6, 2.8, and 3.5 for norovirus GI, GII, and HAV, respectively, obtained for the standard nucleic acid extraction were completely eliminated by the modified protocol. The standard nucleic acid extraction method worked well on drinking water with no RT-qPCR inhibition observed and average recoveries of 80, 124, 89, and 32% for mengovirus, norovirus GI, GII, and HAV, respectively.

Measuring sporadic gastrointestinal illness associated with drinking water - an overview of methodologies

There is an increasing awareness that drinking water contributes to sporadic gastrointestinal illness (GI) in high income countries of the northern hemisphere. A literature search was conducted in order to review: (1) methods used for investigating the effects of public drinking water on GI; (2) evidence of possible dose-response relationship between sporadic GI and drinking water consumption; and (3) association between sporadic GI and factors affecting drinking water quality. Seventy-four articles were selected, key findings and information gaps were identified. In-home intervention studies have only been conducted in areas using surface water sources and intervention studies in communities supplied by ground water are therefore needed. Community-wide intervention studies may constitute a cost-effective alternative to in-home intervention studies. Proxy data that correlate with GI in the community can be used for detecting changes in the incidence of GI. Proxy data can, however, not be used for measuring the prevalence of illness. Local conditions affecting water safety may vary greatly, making direct comparisons between studies difficult unless sufficient knowledge about these conditions is acquired. Drinking water in high-income countries contributes to endemic levels of GI and there are public health benefits for further improvements of drinking water safety.