Are waterborne astrovirus implicated in acute digestive morbidity (E.MI.R.A. study)?

Ubiquitous waterborne pathogens

Water is one of the most important substances on earth and without it life cannot exist. However, poor water quality in many parts of the world has increased the number of water-related diseases, making it the leading cause of disease and death globally for both young and old. Waterborne pathogens cause diseases in humans through two major exposure pathways: drinking water and recreational waters. This chapter on waterborne pathogens will be starting with an introduction, followed by descriptions on classical waterborne pathogens; bacteria, viruses, protozoans, and helminths placing emphasis on the World Health Organization guidelines. Further to conventional waterborne pathogens, fresh organisms and new strains from already known pathogens are being identified and that present important additional challenges to both the water and public health sectors. Hence later part of the chapter focuses on the potential waterborne pathogens and will conclude with a summary of the content.

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.

Characterization of astrovirus-associated gastroenteritis in hospitalized children under five years of age

PURPOSE

The aim of this study was to determine the incidence and genetic diversity of astrovirus (AstV) detected in children hospitalized for gastroenteritis (GE).

METHODS

A multi-center, hospital-based surveillance study was conducted across Lebanon to investigate the incidence of AstV among diarrheal hospitalizations. Viral RNA was extracted from stool samples collected between 2011 and 2013 from children, below the age of 5years, hospitalized for GE at six medical centers across Lebanon. Demographic and clinical data were collected and analyzed. RNA of eligible samples (n=739) was screened by two AstV-specific PCR assays followed by genotype-specific PCR. Sanger sequencing and phylogenetic analysis were performed for genotypic characterization.

RESULTS

Overall, 5.5% (41/739) of rotavirus-negative stool samples collected from hospitalized children <5years old tested positive for AstV infection. AstV infections were detected all year long. Diarrhea, dehydration, vomiting and fever were the most common symptoms associated with AstV infections. Children aged 48-59months had the highest incidence of AstV. Using the Vesikari Scoring System to assess clinical severity, 85.4% of children with AstV had a score>11, indicating severe GE. Genotype-specific PCR identified 22 classical and 4 MLB-like AstV specimens. Further sequencing and phylogenetic analysis of orf1b and orf2 genes revealed that AstV classical 1-3, 5, 6, and 8, MLB-1, VA-1 and -2 genotypes circulated in Lebanon. Recombination between classical AstV strains was detected in several cases as evident by the lack of congruency in the tree topologies of the orf1b and orf2. Two cases of mixed infections between classical and non-classical genotypic strains were recorded.

CONCLUSION

High genetic diversity was detected among AstVs in Lebanon. AstVs are associated with 5.5% of non-rotavirus GE-associated hospitalizations in children under five years in Lebanon.

Epidemiology of Classic and Novel Human Astrovirus: Gastroenteritis and Beyond

Since they were identified in 1975, human astroviruses have been considered one of the most important agents of viral acute gastroenteritis in children. However, highly divergent astroviruses infecting humans have been recently discovered and associated with extra-intestinal infections. The report of cases of fatal meningitis and encephalitis, especially in immunocompromised individuals, has broadened their disease spectrum. Although zoonotic transmission among animal and human astroviruses has not been clearly recognized, the genetic similarity between some human and animal viruses makes it likely to occur. This review provides an update on the epidemiology of both classic and novel human astroviruses, and a comprehensive view on confirmed or potential association between astrovirus and human disease.

Wastewater Analysis Indicates that Genetically Diverse Astroviruses, Including Strains Belonging to Novel Clades MLB and VA, Are Circulating within Japanese Populations

Human astroviruses (HAstVs) are a common etiological agent of infantile gastroenteritis. Recent studies revealed that novel astrovirus (AstV) strains of the MLB clade (MLB-AstVs) and VA clade (VA-AstVs), which are genetically distinct from the classic HAstVs, are circulating in the human population. In the present study, we quantified classic HAstVs as well as carried out a genetic analysis of classic and novel HAstVs in wastewater in Japan. The concentration of classic HAstVs in the influent water samples ranged from 10(4) to 10(5) copies per liter, and the amount removed by wastewater treatment was determined to be 2.4 ± 0.3 log10. Four types of classic HAstV strains (HAstV types 1, 2, 5, and 4/8) as well as novel AstV strains belonging to the MLB-2, VA-1, and VA-2 clades were identified using reverse transcription-PCR (RT-PCR) assays, including assays newly developed for the detection of strains of the MLB and VA clades, followed by cloning and nucleotide sequencing. Our results suggest that genetically diverse AstV strains are circulating among the human population in Japan. The newly developed (semi)nested RT-PCR assays for these novel AstV clades are useful to identify and characterize the novel AstVs in environmental waters.

Human astroviruses

Human astroviruses (HAtVs) are positive-sense single-stranded RNA viruses that were discovered in 1975. Astroviruses infecting other species, particularly mammalian and avian, were identified and classified into the genera Mamastrovirus and Avastrovirus. Through next-generation sequencing, many new astroviruses infecting different species, including humans, have been described, and the Astroviridae family shows a high diversity and zoonotic potential. Three divergent groups of HAstVs are recognized: the classic (MAstV 1), HAstV-MLB (MAstV 6), and HAstV-VA/HMO (MAstV 8 and MAstV 9) groups. Classic HAstVs contain 8 serotypes and account for 2 to 9% of all acute nonbacterial gastroenteritis in children worldwide. Infections are usually self-limiting but can also spread systemically and cause severe infections in immunocompromised patients. The other groups have also been identified in children with gastroenteritis, but extraintestinal pathologies have been suggested for them as well. Classic HAstVs may be grown in cells, allowing the study of their cell cycle, which is similar to that of caliciviruses. The continuous emergence of new astroviruses with a potential zoonotic transmission highlights the need to gain insights on their biology in order to prevent future health threats. This review focuses on the basic virology, pathogenesis, host response, epidemiology, diagnostic assays, and prevention strategies for HAstVs.

Natural persistence of food- and waterborne viruses

This chapter summarises data on the persistence of food-and waterborne viruses in the natural environment and discusses the different factors which can affect this persistence. Conventional and alternative methods by which persistence can be studied are described, and the natural factors influencing virus persistence outside the host organism are discussed. Available data concerning virus persistence in water, soil, on surfaces and in food products are reviewed.

Comparative study of enteric viruses, coliphages and indicator bacteria for evaluating water quality in a tropical high-altitude system

BACKGROUND

Bacteria used as indicators for pathogenic microorganisms in water are not considered adequate as enteric virus indicators. Surface water from a tropical high-altitude system located in Mexico City that receives rainwater, treated and non-treated wastewater used for irrigation, and groundwater used for drinking, was studied.

METHODS

The presence of enterovirus, rotavirus, astrovirus, coliphage, coliform bacteria, and enterococci was determined during annual cycles in 2001 and 2002. Enteric viruses in concentrated water samples were detected by reverse transcriptase-polymerase chain reaction (RT-PCR). Coliphages were detected using the double agar layer method. Bacteria analyses of the water samples were carried out by membrane filtration.

RESULTS

The presence of viruses and bacteria in the water used for irrigation showed no relationship between current bacterial indicator detection and viral presence. Coliphages showed strong association with indicator bacteria and enterovirus, but weak association with other enteric viruses. Enterovirus and rotavirus showed significant seasonal differences in water used for irrigation, although this was not clear for astrovirus.

CONCLUSION

Coliphages proved to be adequate faecal pollution indicators for the irrigation water studied. Viral presence in this tropical high-altitude system showed a similar trend to data previously reported for temperate zones.

New tools for the study and direct surveillance of viral pathogens in water

Half a century ago scientists attempted the detection of poliovirus in water. Since then other enteric viruses responsible for gastroenteritis and hepatitis have replaced enteroviruses as the main target for detection. However, most viral outbreaks are restricted to norovirus and hepatitis A virus, making them the main targets in water. The inclusion of virus analysis in regulatory standards for viruses in water samples must overcome several shortcomings such as the technical difficulties and high costs of virus monitoring, the lack of harmonised and standardised assays and the challenge posed by the ever-changing nature of viruses. However, new tools are nowadays available for the study and direct surveillance of viral pathogens in water that may contribute to fulfil these requirements.

Molecular detection and characterization of gastroenteritis viruses occurring naturally in the stream waters of Manaus, central Amazonia, Brazil

To assess the presence of the four main viruses responsible for human acute gastroenteritis in a hydrographic network impacted by a disordered urbanization process, a 1-year study was performed involving water sample collection from streams in the hydrographic basin surrounding the city of Manaus, Amazonas, Brazil. Thirteen surface water sample collection sites, including different areas of human settlement characterized as urban, rural, and primary forest, located in the Tarumã-Açu, São Raimundo, Educandos, and Puraquequara microbasins, were defined with a global positioning system. At least one virus was detected in 59.6% (31/52) of the water samples analyzed, and rotavirus was the most frequent (44.2%), followed by human adenovirus (30.8%), human astrovirus (15.4%), and norovirus (5.8%). The viral contamination observed mainly in the urban streams reflected the presence of a local high-density population and indicated the gastroenteritis burden from pathogenic viruses in the water, principally due to recreational activities such as bathing. The presence of viral genomes in areas where fecal contamination was not demonstrated by bacterial indicators suggests prolonged virus persistence in aquatic environments and emphasizes the enteric virus group as the most reliable for environmental monitoring.

Chapter 7 Global Supply of Virus-Safe Drinking Water

This chapter illustrates the recommendations and guidelines of the World Health Organization (WHO) concerning water, sanitation, and health. The recommendations and guidelines are evaluated in the light of disease caused by human pathogenic viruses. The guidelines outline a preventive management framework for safe drinking water. The framework includes health-based targets to assist national authorities who are normally responsible to set the targets for the protection of public health from risks by exposure to drinking water. Assessing the adequacy of systems, defining and monitoring control measures, and establishing management plans are the three components of the so-called water safety plans. Achievement of health-based targets may be verified by independent surveillance to assess the safety of the drinking water through additional verification or audit-based approaches. This framework for safe drinking water can be adapted according to environmental, social, economic, and cultural circumstances of drinking water provision on the national, regional, and local level. The chapter concludes that viruses could be considered as biocolloids with specific properties such as size, shape, structure, charge, composition, and genome. These viral characteristics determine their behavior in the environment, resistance to natural inactivation and treatment, and disinfection processes. For each (re-)emerging virus these properties may be known or could be assessed predicting the effectiveness of possible intervention measures for prevention of waterborne disease.

Genotypes and molecular epidemiology of human astroviruses in hospitalized children with acute gastroenteritis in Rio de Janeiro, Brazil

Human astrovirus (HAstV) is an important pathogen that causes acute gastroenteritis mainly in children up to 5 years old worldwide. A total of 318 fecal samples were collected from January to December of 2004 from children with acute gastroenteritis hospitalized in Rio de Janeiro (RJ), Brazil. The samples were obtained from three public hospitals and were previously investigated for the presence of rotavirus (RV) and enteric adenovirus (AdV). The aim of this study was to determine the prevalence and molecular characterization of HAstV by reverse-transcription polymerase chain reaction (RT-PCR) and partial sequencing of open reading frame 2 (ORF2). HAstV infections were detected in 43 (14%) of the samples, of which 19 (6%) were mixed infections with HAstV and RV. HAstV were identified in all age groups, with 85% of the cases occurring in children younger than 2 years old. HAstV infections were more prevalent from March to May. Diarrhea, vomiting, and fever were the main clinical manifestations observed in these infections. Partial capsid sequencing of 35 HAstV strains characterized 25 (71%) as genotype 1 (HAstV-1), 6 (17%) HAstV-2, 3 (9%) HAstV-8, and 1 (3%) HAstV-4. Based on the genetic variability, three lineages were observed between RJ HAstV-1 strains. This study demonstrated the importance of HAstV infections causing acute infantile gastroenteritis in hospitalized children in RJ, Brazil. Molecular epidemiological surveillance is helpful for designing prevention strategies of HAstV transmission.

Waterborne microbial risk assessment: a population-based dose-response function for Giardia spp. (E.MI.R.A study)

BACKGROUND

Dose-response parameters based on clinical challenges are frequently used to assess the health impact of protozoa in drinking water. We compare the risk estimates associated with Giardia in drinking water derived from the dose-response parameter published in the literature and the incidence of acute digestive conditions (ADC) measured in the framework of an epidemiological study in a general population.

METHODS

The study combined a daily follow-up of digestive morbidity among a panel of 544 volunteers and a microbiological surveillance of tap water. The relationship between incidence of ADC and concentrations of Giardia cysts was modeled with Generalized Estimating Equations, adjusting on community, age, tap water intake, presence of bacterial indicators, and genetic markers of viruses. The quantitative estimate of Giardia dose was the product of the declared amount of drinking water intake (in L) by the logarithm of cysts concentrations.

RESULTS

The Odds Ratio for one unit of dose [OR = 1.76 (95% CI: 1.21, 2.55)] showed a very good consistency with the risk assessment estimate computed after the literature dose-response, provided application of a 20 % abatement factor to the cysts counts that were measured in the epidemiological study. Doing so, a daily water intake of 2 L and a Giardia concentration of 10 cysts/100 L, would yield an estimated relative excess risk of 12 % according to the Rendtorff model, against 11 % when multiplying the baseline rate of ADC by the corresponding OR. This abatement parameter encompasses uncertainties associated with germ viability, infectivity and virulence in natural settings.

CONCLUSION

The dose-response function for waterborne Giardia risk derived from clinical experiments is consistent with epidemiological data. However, much remains to be learned about key characteristics that may heavily influence quantitative risk assessment results.

Effect of Temperature on the Survival of F-Specific RNA Coliphage, Feline Calicivirus, and Escherichia coli in Chlorinated Water

We compared the survival of F-specific RNA coliphage MS2, feline calicivirus, and E. coli in normal tap water and in tap water treated to an initial concentration of 50 ppm free chlorine and held at 4 degrees C, 25 degrees C, or 37 degrees C for up to 28 days. Our aim was to determine which of these two organisms (coliphage or E. coli) was better at indicating norovirus survival under the conditions of the experiment. There was a relatively rapid decline of FCV and E. coli in 50 ppm chlorine treated water and both organisms were undetectable within one day irrespective of the temperature. In contrast, FRNA phage survived for 7 to 14 days in 50 ppm chlorine treated water at all temperatures. All organisms survived for 28 days in tap water at 4 degrees C, but FCV was undetectable on day 21 and day 7 at 25 degrees C and 37 degrees C, respectively. Greater survival of FRNA phage compared to E. coli in 50 ppm chlorine treated water suggests that these organisms should be further investigated as indicators of norovirus in depurated shellfish, sanitized produce, and treated wastewater which are all subject to high-level chlorine treatment.

Concentration and detection of hepatitis A virus and rotavirus in spring water samples by reverse transcription-PCR

Every year, enteric viruses such as hepatitis A virus (HAV), rotaviruses, and noroviruses are responsible for viral gastro-enteritis and hepatitis reported worldwide. These viruses are mostly transmitted via the faecal-oral route, from direct contact between people, or by ingestion of contaminated food and water. Since only a few viral particles may cause disease, detection of low concentration of these viruses in food matrices is usually complex. The development of methods to concentrate viruses from food matrices is crucial in collecting data for the development of control strategies or for diagnostic purposes. In the present study, samples of bottled spring water were inoculated with known amounts of HAV (strain HM-175), and rotaviruses (strain Wa) viral particles and filtered through positively charged membranes. Elution of viruses attached to the membranes was achieved with a tryptose phosphate broth-glycine buffer. Eluates were further concentrated using Microsep 100. Finally, RNA was extracted using the Qiagen RNeasy kit followed by an evaporation step with a SpeedVac instrument. The detection limit by reverse-transcription (RT-PCR) was at least 10(-1) TCID50%/ml and at least 10(-3) TCID50%/ml for HAV and rotavirus, respectively.

Development of an astrovirus RT–PCR detection assay for use with conventional, real-time, and integrated cell culture/RT–PCR

Astrovirus is a common cause of gastroenteritis in humans that has been determined to be responsible for outbreaks of illness in several countries. Since astrovirus can be waterborne, it is important to be able to identify this virus in environmental water. We have developed and optimized a reverse transcription – polymerase chain reaction (RT–PCR) method that was able to amplify all eight astrovirus serotypes in a single reaction. In addition, a positive control construct was designed so that any inhibitors of this astrovirus assay could be detected. The assay was adapted for use in a real-time PCR assay and the sensitivity of these two methods was compared. The real-time assay was then combined with CaCo2 cell culture to produce an integrated cell culture/RT–PCR (ICC/RT–PCR) assay that was able to detect low levels of astrovirus after an incubation of 7 days or less. Also, the sensitivity of the ICC/RT–PCR assay was compared with RT–PCR alone. The methods were used to detect astrovirus in acute phase illness stool samples as well as in a water sample spiked with astrovirus.Key words: astrovirus, RT–PCR, real-time PCR, ICC/RT–PCR, environmental water.

Quantification of human astroviruses in sewage using real-time RT-PCR

Human astroviruses constitute a significant cause of acute diarrhea in children. Viral transmission occurs via the fecal-oral route, predominantly person-to-person, but the consumption of fecally contaminated water and shellfish has also been implicated. Viral pathogen detection in water, especially, in wastewater, is difficult and PCR is widely used to detect these viruses. Despite the recent development of real-time quantitative PCR, quantification of astroviruses in sewage had not been available up to now. We have developed a method to quantify astroviruses in sewage. For this purpose, we designed a set of primers and a fluorogenic probe located at the 3' -end of the genome of human astroviruses. The amplified region was cloned and the plasmid was transcribed to generate calibration standards for quantification. After validation of the standards, the method was evaluated in artificially contaminated samples. To validate the method on naturally contaminated samples, raw and treated wastewater samples were collected monthly for one year in a sewage treatment plant. Astrovirus genomes were detected in all samples collected at the entrance to the sewage treatment plant, with a mean value of 4.1 x 10(6) astrovirus genomes for 100 ml. Effluents were less strongly contaminated, with a mean value of 1.01 x 10(4) astrovirus genomes. The high prevalence of astroviruses in sewage treatment plant effluents indicates that these plants are not efficiently eliminating the virus. This is a major public health concern and new techniques of depuration are needed. Our method could be effectively used in evaluating new treatment processes to reduce the viral load in the effluent of treatment plants.