[Urban green and blue spaces in times of climate change]

Both climate mitigation and adaptation are urgently needed as complementary strategies for sustainably reducing and managing urban health risks posed by climate change. The positive effects of urban green and blue spaces on physical and mental health are well-known since decades. However, there is intensive competition around the use of the urban space. Reflecting the European Aalborg Charta (1994), German building laws require development plans to be sustainable in this demanding context with human health being a concern of central importance. Reality, however, remains challenging. Although there are numerous best practice examples, research on the impact of urban green and blue spaces on human health and well-being is still required. Furthermore, all relevant policy fields need to develop awareness of the importance of green and blue spaces for quality of life and health, so that the issue of health is taken into consideration adequately as well as in a socially sensitive manner in urban decision processes.

Effect of portable HEPA filters on COVID-19 period prevalence: an observational quasi-interventional study in German kindergartens

OBJECTIVES

The aim of the study was to evaluate the effect of high-efficiency particulate air (HEPA) filters on COVID-19 period prevalence in kindergartens.

DESIGN

The observational study follows an intervention design with the intervention group using HEPA filters and the control group not.

SETTING

The study was conducted in 32 (10 intervention, 22 control) kindergartens (daycare centres) in Rhineland Palatinate (Germany).

PARTICIPANTS

Data of 2360 children (663 intervention, 1697 control) were reported by the kindergarten heads. Data were collected on institutional level without any identifying information on individuals. Thus, all children of all facilities were included; however, no demographic data were recorded.

INTERVENTIONS

The study followed a quasi-interventional design, as no formal intervention was conducted. A charity foundation equipped kindergartens with HEPA filters. These kindergartens were enrolled as intervention group. The control group was recruited from the neighbouring communities and districts.

OUTCOME MEASURES

The primary outcome measure was the number of COVID-19 cases reported by the kindergarten heads, converted into period prevalence rates per 1000 population.

RESULTS

The mean COVID-19 period prevalence rates of the control and intervention groups were 186 (95% CI: 137.8 to 238.9) and 372 (95% CI: 226.6 to 517.6) per 1000 children, respectively. The one-sided Wilcoxon rank-sum test indicates a p value of 0.989; thus, the hypothesised preventive effect of HEPA filters could not be confirmed in the kindergarten setting.

CONCLUSIONS

While HEPA filters can significantly reduce the viral load in room air, this does not lead to reduced COVID-19 prevalence in the selected kindergartens in Germany. It is known that contagion mainly occurs via direct face-to-face air exchange during play and that the contaminated air does not necessarily pass through the filter prior to air exchange between children. The use of HEPA filters may also lead to a sense of security, leading to reduced preventive behaviour.

Legionella in drinking water: the detection method matters

Legionella concentrations in drinking water have been regulated for decades and are evaluated with regard to their concentrations in drinking water plumbing systems (DWPS). The respective action levels differ at the international level. In Germany, the Federal Environment Agency (UBA) specifies the application of ISO 11731 for the detection of legionella in drinking water and gives a binding recommendation for the methods to be used for culturing and evaluation. Effective from 01 March 2019, the UBA recommendation was revised. The utilized culture media in the culture approach were altered, consequently affecting the spectrum of legionella colonies detected in drinking water. Using data from a routine legionella monitoring of a large laboratory, over a period of 6 years and 17,270 individual drinking water samples, allowed us to assess the impact of the alteration on the assessment of DWPS. By comparing the amount of action level exceedances before and after the method change, it could be demonstrated that exceedances are reported significantly more often under the new method. Consequently, the corresponding action level for evaluation of legionella contamination and the resulting risk to human health needs to be revised to avoid the misleading impression of increased health risk.

Contamination Landscapes: Spatio-Temporal Record and Analysis of Pathogens in Clinical Settings

Nosocomial outbreaks require quick epidemiological clarification of possible chains of infection, since the pathogen usually has a head start that has to be caught up. Identification of people and areas at risk is crucial for efficient confinement. This paper describes a concept which can be applied to healthcare settings. The application skips the time-consuming and imperfect reconstruction of direct and indirect contacts. Indoor mobility of people and devices are instead measured precisely, and the mobility history is used to construct a spatio-temporal 'landscape of infection'. This landscape allows for the calculation of a modelled 'contamination landscape' (CL) adding location-based prolongation of infectivity. In that way, the risk per person can be derived in case of an outbreak. The CL concept is extremely flexible and can be adapted to various pathogen-specific settings. The combination of advanced measurements and specific modelling results in an instant list of possible recipients who need to be examined directly. The modelled, pathogen-specific parameters can be adjusted to get as close as possible to the results of mass screenings.

Coping with ill-health while lacking access to health care: Acceptability of health service provision in rural Malawi - a qualitative study

BACKGROUND

Large parts of Malawi`s population lack access to health care. A high burden of disease, chronic poverty, and a growing population accelerate the need for extending and improving health care. One region that is struggling with service provision is Malawi´s rural district Phalombe. In addition to adequate resources, acceptability of service provision and productive patient-provider engagements are crucial determinants of health-seeking behaviour.

OBJECTIVE

This study aimed to better understand the interdependencies between acceptability, patient-provider engagement, and health-seeking behaviour in Phalombe. By targeting health care providers and community members, different perspectives were assessed and triangulated.

METHODS

Following a qualitative approach, group interviews were conducted with community members of three rural villages (n = 21) in Phalombe. Semi-structured interviews (n = 2) and a group interview among management staff (n = 3) provided insight into experiences of health care providers.

RESULTS

Community members perceived health care providers' behaviour as disrespectful, resulting in power gaps between patients and providers. Providers blamed community members' cultural beliefs and lack of awareness regarding health care as barriers to seek formal services. Systemic shortcomings diminished community members' trust in service provision, while increasing frustration among providers and thus impacting patient-provider engagement. Due to insufficient resources, lack of acceptability and trust in receiving adequate services, potential patients turned into non-users of health care.

CONCLUSIONS

A patient-centred approach is needed that empowers communities by involving them in health care planning, in facility management, and by raising awareness towards health issues. Trainings for providers need to focus on improving communication and building trustful patient-provider interactions. Yet, without addressing systemic constraints, providers' frustration and patients' lack of trust in service provision will remain and impact their health-seeking behaviour. Thus, further budget needs to be allocated to Malawi's health care sector in order to provide resources needed.

School water, sanitation, and hygiene (WaSH) intervention to improve malnutrition, dehydration, health literacy, and handwashing: a cluster-randomised controlled trial in Metro Manila, Philippines

BACKGROUND

The impacts of multicomponent school water, sanitation, and hygiene (WaSH) interventions on children's health are unclear. We conducted a cluster-randomized controlled trial to test the effects of a school WaSH intervention on children's malnutrition, dehydration, health literacy (HL), and handwashing (HW) in Metro Manila, Philippines.

METHODS

The trial lasted from June 2017 to March 2018 and included children, in grades 5, 6, 7, and 10, from 15 schools. At baseline 756 children were enrolled. Seventy-eight children in two clusters were purposively assigned to the control group (CG); 13 clusters were randomly assigned to one of three intervention groups: low-intensity health education (LIHE; two schools, n = 116 children), medium-intensity health education (MIHE; seven schools, n = 356 children), and high-intensity health education (HIHE; four schools, n = 206 children). The intervention consisted of health education (HE), WaSH policy workshops, provision of hygiene supplies, and WaSH facilities repairs. Outcomes were: height-for-age and body mass index-for-age Z scores (HAZ, BAZ); stunting, undernutrition, overnutrition, dehydration prevalence; HL and HW scores. We used anthropometry to measure children's physical growth, urine test strips to measure dehydration, questionnaires to measure HL, and observation to measure HW practice. The same measurements were used during baseline and endline. We used multilevel mixed-effects logistic and linear regression models to assess intervention effects.

RESULTS

None of the interventions reduced undernutrition prevalence or improved HAZ, BAZ, or overall HL scores. Low-intensity HE reduced stunting (adjusted odds ratio [aOR] 0.95; 95% CI 0.93 to 0.96), while low- (aOR 0.57; 95% CI 0.34 to 0.96) and high-intensity HE (aOR 0.63; 95% CI 0.42 to 0.93) reduced overnutrition. Medium- (adjusted incidence rate ratio [aIRR] 0.02; 95% CI 0.01 to 0.04) and high-intensity HE (aIRR 0.01; 95% CI 0.00 to 0.16) reduced severe dehydration. Medium- (aOR 3.18; 95% CI 1.34 to 7.55) and high-intensity HE (aOR 3.89; 95% CI 3.74 to 4.05) increased observed HW after using the toilet/urinal.

CONCLUSION

Increasing the intensity of HE reduced prevalence of stunting, overnutrition, and severe dehydration and increased prevalence of observed HW. Data may be relevant for school WaSH interventions in the Global South. Interventions may have been more effective if adherence was higher, exposure to interventions longer, parents/caregivers were more involved, or household WaSH was addressed.

TRIAL REGISTRATION NUMBER

DRKS00021623.

Diarrhoea, malnutrition, and dehydration associated with school water, sanitation, and hygiene in Metro Manila, Philippines: A cross-sectional study

INTRODUCTION

Diarrhoea, malnutrition, and dehydration threaten the lives of millions of children globally due to inadequate water, sanitation, and hygiene (WaSH). Our study aimed to identify environmental and behavioural risk factors of these health outcomes among schoolchildren in Metro Manila, Philippines.

MATERIALS AND METHODS

We analysed data from a multistage cluster sample of schoolchildren in grades 5, 6, 7, 9, and 10 (ages ~10-15 years old) to investigate WaSH facilities and hygiene practices. Outcomes were: self-reported diarrhoea, measured via questionnaire; observed malnutrition (stunting, undernutrition [underweight/thin and wasted/severely thin], over-nutrition [overweight and obese]), measured via anthropometry; dehydration, measured via urine specific gravity/urine test strips. We used multiple logistic regression to explore correlates.

RESULTS

We included 1558 students from 15 schools in three cities. Over 28% (421) of students had diarrhoea and 68% (956) were dehydrated. Over 15% (227) of students were stunted, ~9% (127) were undernourished, and >21% (321) were over-nourished. Diarrhoea was associated with poor handwashing, while dehydration was associated with the lack of water in school restrooms. Stunting was linked with not using the school restroom, the lack of water in school restrooms, and the lack of hygiene lessons in school. Undernutrition was associated with the lack of a school restroom cleaning policy. Risks of diarrhoea, stunting, and undernutrition decreased as the number of school restrooms increased. Risks of stunting and overnutrition decreased as the numbers of school toilets increased. Having more than seven handwashing basins was associated with decreased risk of dehydration.

DISCUSSION

Findings from our cross-sectional study cannot describe causation. We have found associations that suggest that school restroom cleaning policies, adequate water supply, improved handwashing, and hygiene education are needed to prevent disease. School-based WaSH interventions are recommended to provide water in school WaSH facilities, promote handwashing, and improve hygiene-related knowledge.

Associations between socio-spatially different urban areas and knowledge, attitudes, practices and antibiotic use: A cross-sectional study in the Ruhr Metropolis, Germany

Inappropriate and excessive antibiotic use fuels the development of antibiotic resistance. Determinants of antibiotic use, including knowledge and attitudes, are manifold and vary on different spatial scales. The objective of this study was to examine the associations between socio-spatially diverse urban areas and knowledge, attitudes, practices and antibiotic use within a metropolitan city. A cross-sectional survey was conducted in the general population in socio-spatially different areas in Dortmund, Germany, in February and March 2020. Three urban areas were chosen to represent diverse socio-spatial contexts (socio-spatially disadvantaged: A, intermediate: B, socio-spatially disadvantaged: C). Participants were selected via simple random sampling. The questionnaire comprised knowledge and attitude statements and questions around antibiotic use and handling practices. Differences between the areas were examined by estimating odds ratios (OR) and corresponding 95% confidence intervals by multiple logistic regression. Overall, 158 participants were included. Participants of Area C showed the lowest proportions of correct knowledge statements, indicated more often attitudes contrary to common recommendations, lower risk awareness and reported more often antibiotic use (C: 40.8%; A: 32.7%; B: 26.5%) and potential mishandling practices (C: 30.4%; A: 9.6%; B: 17.3%). The multiple logistic regression confirmed these differences. Around 42.3% (C), 33.3% (A) and 20.0% (B) of the diseases mentioned for which an antibiotic was used are mainly caused by viral pathogens. A common misconception across all areas was the perception of antibiotic resistance as an individual rather than a universal issue. This study reveals distinct differences between socio-spatially diverse urban areas within a metropolitan city, regarding knowledge, attitudes and practices around antibiotics and ABR. Our findings confirm that enhanced efforts are required to better inform the population about the adequate use and handling of antibiotics. This study emphasizes the need for future interventions to be tailored to the specific local socio-economic context.

The Regeneration of Urban Blue Spaces: A Public Health Intervention? Reviewing the Evidence

Research in recent years has demonstrated that urban surface waters (“urban blue spaces”) can provide beneficial effects on human health and wellbeing. Despite blue spaces prevailing on urban development agendas across the world, little investigation has been done whether and how the regeneration of such spaces is used as a (community-based) public health intervention. Therefore, a review was conducted to analyze urban blue space regeneration projects in terms of their significance for public health. Results show that the regeneration of urban blue spaces displays a diversity of intervention types and follows certain development trends seen in general urban regeneration: Similarities mainly arise in relation to objectives (multi-dimensional goals with increasing focus on environmental sustainability and economic interests), stakeholders (shift to multi-actor governance with a rise of partnerships and community participation), and funding (prevalence of mixed financial schemes and increasing reliance on external funding sources). Although threefold public health effects have been noted across the projects (i. behavioral changes toward healthier lifestyles, ii. healthier urban environments, iii. health policy changes), results of this review indicate that the potential to use urban blue regeneration as a community-based health intervention has yet to be realized.

Antibiotic resistance in wastewater from socio-spatially different communities

 

Antibiotic resistance (ABR) and the spread of multidrug-resistant organisms (MDRO) via wastewater are of global health concern. Simultaneously, wastewater-based surveillance is a promising approach to gain an overview of the local ABR situation providing complementary public health data at lower costs. Research on the general community as one of the biggest dischargers is rather scarce. The objective of this study was to explore spatial and temporal differences in the occurrence of MDRO in community wastewater from socio-spatially different districts. Wastewater from three socio-spatially different districts in the Ruhr Metropolis, Germany, was sampled monthly over a year and analysed for extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli via culture-based methods. Isolates were validated with matrix assisted laser desorption ionization time of flight mass spectrometry. Antibiotic resistance profiles were analysed via microdilution. Phenotypic ESBL-producing E. coli could be isolated from every wastewater sample. The socio-spatially disadvantaged area displayed higher ESBL-producing E. coli loads adjusted for domestic discharge and inhabitants (median: 3.8e+8 CFU/d/inh.) compared to the other two areas (socio-spatially advantaged: 1.5e+8 CFU/d/inh. and socio-spatial average: 2.0e+8 CFU/d/inh.). Aggregated into seasons, values were highest for the winter season. Resistance profiles varied only for those antibiotics, which can be administered in outpatient care, showing lower resistance levels in the socio-spatially advantaged area. The general community is an important contributor of ESBL-producing E. coli in wastewater. Spatial and seasonal influences of ESBL-producing E. coli in wastewater between different communities, depicting the human outpatient sector, are identifiable and suggest a higher ABR burden in a socio-spatially disadvantaged area and during the winter season, as well as lower resistance levels in a socio-spatially advantaged area.

Key messages

The general community is a relevant source of multidrug-resistant bacteria in wastewater with observable spatial and seasonal influences between socio-spatially different communities. Findings suggest small-scale differences with a higher antibiotic resistance burden in a socio-spatially disadvantaged area and lower resistance levels in a socio-spatially advantaged area.

Prevalence of multidrug-resistant and extended-spectrum beta-lactamase-producing Escherichia coli in urban community wastewater

Antibiotic resistance (ABR) and the spread of multidrug-resistant and extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli via wastewater to environmental compartments are of rapidly growing global health concern. Health care facilities, industries and slaughterhouses discharge high loads of ABR bacteria with their wastewater. However, the general community is often the biggest indirect discharger. Yet, research focusing explicitly on this important diffuse source is rather scarce raising questions about variations in the occurrence of ESBL-producing E. coli in wastewater from different communities and over time. Between April 2019 and March 2020, wastewater from three socio-spatially different districts in the Ruhr Metropolis, Germany, and the receiving wastewater treatment plant was sampled monthly and analysed for the occurrence of ESBL-producing E. coli via culture-based methods. Isolates were validated with matrix assisted laser desorption ionization time of flight mass spectrometry and antibiotic resistance profiles were analysed via microdilution. Results were interpreted using the European Committee on Antimicrobial Susceptibility Testing criteria. The German Commission for Hospital Hygiene and Infection Prevention criteria were used for multidrug-resistance categorization. Phenotypic ESBL-producing E. coli could be isolated from every wastewater sample demonstrating that the general community is an important indirect discharger. The socio-spatially disadvantaged area displayed higher absolute loads of ESBL-producing E. coli compared to the other two areas, as well as higher adjusted loads for domestic discharge and inhabitants, particularly during winter, indicating a higher ABR burden. Thirty-two isolates (28.6%) were characterized as multidrug-resistant Gram-negative bacteria (3MRGN). Resistance profiles varied only for those antibiotics, which can be administered in outpatient care. Resistance levels tended to be around 10% lower in the socio-spatially advantaged area. This study shows that spatial and seasonal influences regarding the occurrence of ESBL-producing E. coli in wastewater from socio-spatially different communities are identifiable.

Air filtration as a tool for the reduction of viral aerosols

For testing the effectiveness of air purification devices in regard to the reduction of virus-containing aerosols, a test method involving test viruses has been lacking until now. The use of bacteriophages (phiX174 phages) is a method to test the efficiency of air purification devices under experimental conditions. Using air purifiers with a HEPA filter H14, a 4.6-6.1 Log reduction of test viruses can be achieved if bacteriophages are directly aerosolised into the air purifier, which corresponds to a reduction of 99.9974-99.9999%. Due to the complexity and individuality of air flow, an experimental approach was used in which all outside influences were minimised. The experimental setup was practical and chosen to project a scenario of direct transmission by an emitting source to a recipient. The experiments were performed with and without the air purifier at a distance of 0.75 m and 1.5 m each. Using the air purifier at a setting of 1000 m³/h, the concentration of the phiX174 phages in the air could be reduced by 2.86 Log (mean value). Nevertheless, the experiments without the air purifier showed a similar reduction rate of 2.61 Log (mean value) after 35 min. The concentration of phiX174 phages in the air could be additionally reduced up to 1 log step (maximum value) by the use of the air purifier in comparison to the experiments without. Distance was shown to be an important factor for risk reduction.

Antibiotic-Resistant Bacteria in Clams-A Study on Mussels in the River Rhine

Bacterial infections have been treated effectively by antibiotics since the discovery of penicillin in 1928. A worldwide increase in the use of antibiotics led to the emergence of antibiotic resistant strains in almost all bacterial pathogens, which complicates the treatment of infectious diseases. Antibiotic-resistant bacteria play an important role in increasing the risk associated with the usage of surface waters (e.g., irrigation, recreation) and the spread of the resistance genes. Many studies show that important pathogenic antibiotic-resistant bacteria can enter the environment by the discharge of sewage treatment plants and combined sewage overflow events. Mussels have successfully been used as bio-indicators of heavy metals, chemicals and parasites; they may also be efficient bio-indicators for viruses and bacteria. In this study an influence of the discharge of a sewage treatment plant could be shown in regard to the presence of E. coli in higher concentrations in the mussels downstream the treatment plant. Antibiotic-resistant bacteria, resistant against one or two classes of antibiotics and relevance for human health could be detected in the mussels at different sampling sites of the river Rhine. No multidrug-resistant bacteria could be isolated from the mussels, although they were found in samples of the surrounding water body.

Clinically relevant antibiotic-resistant bacteria in aquatic environments - An optimized culture-based approach

The emergence of antibiotic-resistant clinically relevant facultative pathogenic bacteria in the environment has become one of the most important global health challenges. Antibiotic-resistant bacteria (ARB) have been found in surface waters and wastewater treatment plants. Drinking water guidelines and the EU bathing water directive 2006/7/EC include the surveillance of defined microbiological parameters on species level, while the monitoring of ARB is missing in all existing guidelines. However, standardized methods for the detection of ARB exist for clinical investigations of human materials only. They are based on cultivation on selective agar plates. These methods cannot be used directly for environmental samples, because of the high amount and diversity of bacterial background flora which interferes with the detection of human-relevant ARB. The aim of this study was to introduce a proposal for future normative standard operation procedures, with international relevance, for the culture-based detection of clinically-relevant antibiotic resistant bacteria in aquatic environmental samples like wastewater and surface water: gram-negative bacteria resistant against 3rd generation cephalosporins (ESBL) and against carbapenems (CARBA), gram-positive vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). The final adaptation of standardized cultivation methods included increasing the standard incubation temperature from 36 °C to 42 °C, which effectively inhibits the environmental background flora on agar plates while the desired target species survive. This enables the detection of target species in suitable sample volumes. Putative target colonies which belong to the remaining background flora had to be excluded by morphological and physiological differentiation. Therefore, a time and cost optimized testing scheme with good performance was developed, which allows an effective exclusion of non-target isolates in samples. Depending on the target species and sample type, sensitivity of up to 100% is achieved, and specificity ranges from 91.1% to 99.7%, while the positive predictive value, negative predicted value and accuracy rate are always >90%.

Protocol for a Trial Assessing the Impacts of School-Based WaSH Interventions on Children's Health Literacy, Handwashing, and Nutrition Status in Low- and Middle-Income Countries

Diarrhea, soil-transmitted helminth infection and malnutrition are leading causes of child mortality in low- and middle-income countries (LMICs). To reduce the prevalence of these diseases, effective interventions for adequate water, sanitation, and hygiene (WaSH) should be implemented. This paper describes the design of a cluster-randomized controlled trial that will compare the efficacy of four school-based WaSH interventions for improving children’s health literacy, handwashing, and nutrition. Interventions consisted of (1) WaSH policy reinforcement; (2) low-, medium-, or high-volume health education; (3) hygiene supplies; and (4) WaSH facilities (e.g., toilets, urinals, handwashing basins) improvements. We randomly allocated school clusters from the intervention arm to one of four groups to compare with schools from the control arm. Primary outcomes were: children’s health literacy, physical growth, nutrition status, and handwashing prevalence. Secondary outcomes were: children’s self-reported health status and history of extreme hunger, satisfaction with WaSH facilities, and school restrooms’ WaSH adequacy. We will measure differences in pre- and post-intervention outcomes and compare these differences between control and intervention arms. This research protocol can be a blueprint for future school-based WaSH intervention studies to be conducted in LMICs. Study protocols were approved by the ethics committees of the University of Bonn, Germany, and the University of the Philippines Manila. This trial was retroactively registered, ID number: DRKS00021623.

Small-scaled association between ambient temperature and campylobacteriosis incidence in Germany

Campylobacteriosis is the leading bacterial cause of human diarrheal illness worldwide. Campylobacteriosis incidence exhibits seasonality and has been attributed to ambient temperature. However, the role of ambient temperature on campylobacteriosis remains poorly understood. To examine the impact of ambient temperature on local campylobacteriosis in Germany, weekly incidences on NUTS-3 level were analysed using a novel small-scaled approach, regression and time lags. Campylobacteriosis incidence correlated positively with temperatures between - 5 and 28 °C. The sigmoid regression model estimated an incidence increase of 0.52 per 5 °C temperature rise in the observation period. The weekly average of daily minimum temperature was most significant at a time lag of two weeks and showed the steepest incidence increase of 0.13 per 1 °C temperature increase in a temperature corridor of 5.1 to 12.2 °C. The impact of average minimum temperatures on campylobacteriosis incidence is crucial, likely to be indirect and especially relevant in the recent part of the infection chain. Vectors or human behaviour are presumably more directly linked with temperature than the pathogen's microbiology and should be examined. These variables outweigh the direct temperature-pathogen relationship when the whole chain of infection is considered. In the context of climate change, campylobacteriosis is likely to increase in Germany due to an increased temperature effect.

Water, sanitation and hygiene in health facilities and how they affect health in European countries

Background

Water, sanitation and hygiene (WASH) are human rights as well as important targets of the Sustainable Development Goals and a key component of quality of healthcare. Poor access to safe WASH impacts patients' health as it increases the risk of contracting infectious diseases, mental distress or avoidance of WASH services with additional negative health consequences. Global statistics show that the greatest risk exists in developing countries, while there is little data available from the WHO European Region. Our research aims at gathering an up-to-date overview of WASH data and health consequences on the example of a number of districts from four middle- and high-income countries in the European Region.

Methods

A mixed-methods analysis was conducted, including literature review, one-shot surveys addressing different types of healthcare services and different socio-economical settings, policy analyses, expert interviews and desk-review of health statistics.

Results

Preliminary results show that differences and commonalities are observed with respect to the WASH provision and management in healthcare across the considered areas in the region. While basic drinking-water is widely provided, other aspects, such as sanitation, are in need of attention both at the regulatory and implementation level. Also within countries, local differences are observed. Conditions of WASH services in health care are linked with the spread of (resistant) nosocomial infections through many different pathogens with consequences for patients, mothers and children, and for the broader population, influencing morbidity and mortality.

Conclusions

New insights on the condition of WASH services in healthcare facilities and increasing relevance of WASH-related health outcomes, such as antimicrobial resistance and nosocomial infections, show the need for increased attention to basic services such as sanitation and hygiene in healthcare also in European countries and for locally-targeted interventions.

Key messages

Water, sanitation and hygiene are a critical component of quality of health care and severely affect staff’s performance and patients’ health, with consequences for the population. Water, sanitation and hygiene need more attention in middle- and high-income countries in the WHO European Region, both at the regulatory and implementation level.

Performance of retention soil filters for the reduction of hygienically-relevant microorganisms in combined sewage overflow and treated wastewater

Environmental quality standards for surface waters have been significantly expanded through recent amendments to German regulations. Limit values are only established for applicable regulations if the water is indicated for certain uses, e.g. abstraction of irrigation water. Nevertheless, surface water bodies are often used for hygiene-sensitive purposes. In the course of climate change, stronger precipitation events will occur, which may lead to more frequent loading and discharge of combined sewer overflow (CSO) into surface water bodies. Retention soil filters (RSFs) are attracting attention as an extensive treatment technology for CSO and additional wastewater treatment. This study examined large-scale RSFs for CSO treatment, as well as the effectiveness of RSFs as a fourth purification stage. An RSF test facility was established at a municipal wastewater treatment plant (WWTP), consisting three semi-technical RSFs that were fed exclusively with treated water from the WWTP. The reduction of microorganisms mostly occurred within the first centimeters of the RSFs. For most hygienic-microbiological parameters, a 1-2 log unit reduction could be detected in addition to the reduction within the WWTP. Antibiotic-resistant bacteria were reduced to the same extent. Investigation of the large-scale RSFs showed that a flow rate reduced by half corresponded to better reduction performances.

Association between antibiotic residues, antibiotic resistant bacteria and antibiotic resistance genes in anthropogenic wastewater - An evaluation of clinical influences

The high use of antibiotics in human and veterinary medicine has led to a wide spread of antibiotics and antimicrobial resistance into the environment. In recent years, various studies have shown that antibiotic residues, resistant bacteria and resistance genes, occur in aquatic environments and that clinical wastewater seems to be a hot spot for the environmental spread of antibiotic resistance. Here a representative statistical analysis of various sampling points is presented, containing different proportions of clinically influenced wastewater. The statistical analysis contains the calculation of the odds ratios for any combination of antibiotics with resistant bacteria or resistance genes, respectively. The results were screened for an increased probability of detecting resistant bacteria, or resistance genes, with the simultaneous presence of antibiotic residues. Positive associated sets were then compared, with regards to the detected median concentration, at the investigated sampling points. All results show that the sampling points with the highest proportion of clinical wastewater always form a distinct cluster concerning resistance. The results shown in this study lead to the assumption that ciprofloxacin is a good indicator of the presence of multidrug resistant P. aeruginosa and extended spectrum β-lactamase (ESBL)-producing Klebsiella spec., Enterobacter spec. and Citrobacter spec., as it positively relates with both parameters. Furthermore, a precise relationship between carbapenemase genes and meropenem, regarding the respective sampling sites, could be obtained. These results highlight the role of clinical wastewater for the dissemination and development of multidrug resistance.

Infectious rain? Evaluation of human pathogen concentrations in stormwater in separate sewer systems

Separate sewer systems collect and discharge rainwater directly into surface water bodies. In residential areas covering moderate traffic load these are alternative drainage routes to avoid combined sewer overflow discharge and to keep rivers clean as required by the EU Water Framework Directive. This overflow's microbial quality, however, needs to be evaluated, since stormwater run-offs are potential pathways for pathogens into river systems. Between 2010 and 2016, two separate sewer systems in North Rhine-Westphalia (Germany) were investigated. The stormwater outflow was sampled during discharge events and microbiologically analysed. The results showed high concentrations of Escherichia coli (1,100-1,100,000 CFU/100 mL) and Clostridium perfringens (20-13,000 CFU/100 mL). Campylobacter and Salmonella were detected in 97% and 43% of the samples. Giardia cysts were more often detected (31.6%) than Cryptosporidium oocysts (10.5%). The sources of human pathogens in rainwater run-off are heterogeneous. While roads have already been declared as chemical polluters via rainwater run-off, our study detected supplementary pollution of mainly faecal microorganisms. Presumably, failed connections in the sewer system itself are important sources of human pathogens. We suggest treatment of stormwater run-offs before being discharged into the river system.

Spatio-Temporal Distribution of Tuberculosis in an Urban Setting in Germany

BACKGROUND

 Big cities in Europe have the highest incidence rates of TB in otherwise low incidence settings. Understanding of the spatio-temporal patterns of TB incidence can support efforts for TB prevention and control in line with the End-TB Strategy of the WHO in such settings for low incidence settings.

METHODS

 Data from the municipal TB register of Cologne collected between 2006 and 2015 under the infection prevention legislation were retrieved, addresses geographically identified and all notified incident TB cases retrospectively analysed for their spatial and temporal distribution in this large German city using a geographic information system.

RESULTS

 During the analysed period 1,038 incident cases were reported, equivalent to an incidence rate of 10.03 cases per 100,000 inhabitants. Contagious pulmonary TB contributed 57 % of all cases. Distribution patterns changed over time with decreases in 37 and increases in 22 of the 77 urban sub-districts, three of which showing constant high rates of TB incidence.

CONCLUSION

 The study presents a complementary method to monitor the distribution and development of incident TB cases at a disaggregated level of urban sub-districts. Identification of areas with comparatively high incidence can support identification of clusters respectively their prevention and allow better planning for targeted local TB services.

Coping with ill-health: health care facility, chemist or medicinal plants? Health-seeking behaviour in a Kenyan wetland

BACKGROUND

Sub-Saharan African wetlands, settlement areas to growing populations, expose their users to diseases as necessary health infrastructure remains underdeveloped.

METHODS

Mixed methods were adopted to assess the health-seeking behaviour of different exposure groups (farmers, pastoralists, service sector workers) in a Kenyan wetland community. Based on a cross-sectional survey (n = 400), syndromic surveillance was linked to health-seeking event analysis. In-depth interviews with community members (n = 20) and experts (n = 8) enabled the integration of healthcare user and provider perspectives.

RESULTS

Health-seeking behaviour in the wetland was determined by physical/infrastructural, natural/environmental, financial/socioeconomic and social/demographic factors, as well as human/cultural aspects such as traditional preferences rooted in health beliefs. Community members had different strategies of coping with ill-health and few symptoms remained untreated. Whether via a health care facility admission, the visit of a chemist, or the intake of pharmaceuticals or medicinal plants: treatment was usually applied either via a healthcare service provider or by the community members themselves. An undersupply of easy-to-reach healthcare options was detected, and healthcare services were not available and accessible to all. The widely-practiced self-treatment of symptoms, e.g. by use of local medicinal plants, mirrors both potential healthcare gaps and cultural preferences of wetland communities.

CONCLUSIONS

Integrated into an overall health-promoting wetland management approach, widely accepted (cultural) realities of health-seeking behaviours could complement health sector service provision and help ensure healthy lives and promote well-being for all in wetlands.

Reduction of micropollutants and bacteria in a constructed wetland for combined sewer overflow treatment after 7 and 10 years of operation

Repeated investigations on constructed wetlands for the treatment of combined sewer overflows, also named bioretention filters or retention soil filters, are necessary to provide information on their long-term performance. In this study, a sampling campaign was conducted on micropollutants, indicator microorganisms and standard parameters ten years after such filters were in operation and three years after the first investigation; it revealed that the filters lost capacity to remove chemical substances with no or only slow biological degradability. This was the case e.g. for phosphate (decrease from 29 to 11%), diclofenac (67 to 34%) and TCPP (34% to negative reduction). They continued to remove easily degradable parameters such as COD (stable around 75%) stably. The indicator microorganisms Escherichia coli (1.1/0.8 log₁₀), intestinal enterococci (1.3/0.8 log₁₀) and somatic coliphages (0.6/1.0 log₁₀) showed comparably low process variations given the difficulties in sampling and analysing microbial parameters representatively as well as given natural variations in microbial behaviour and growth. Additionally, for bisphenol A, we found a temperature-related difference of removal efficiencies: while in the cold months (winter), the removal was only 53% on average, it increased to 90% in the warm months (summer). As for the long-term prospective of retention soil filters, decision-makers need to identify the most important pollutants in a specific catchment area and adapt the filter design accordingly. If pollutants are targeted that lead to an exhausted filtration capacity, post treatment or the exchange of charged filter material is necessary. However, for easily biologically degradable substances, so far, there is no limit in their use.

Impact of wastewater-irrigation on in-household water contamination. A cohort study among urban farmers in Ahmedabad, India

This cohort study explores the contribution of wastewater irrigation, in the context of WASH (Water, Sanitation, Hygiene), on in-household water contamination among urban farming households in Ahmedabad, India. Drinking water samples of 204 households in four peri-urban farming communities were collected from the point-of-source (PoS) and point-of-use (PoU) of each household four times over the 12-month follow-up period. Next to the quantification of E. coli, three household surveys (baseline, hygiene and farm) were conducted. Additionally, an observational spot-check was undertaken in bi-monthly intervals throughout the follow-up period. Significant positive differences in water quality between PoS and PoU samples were identified in 78% of households. During the monsoon, the peak of contamination, only 6% of households had access to safe drinking water at PoU. The Average Treatment Effect (ATE) of wastewater irrigation indicates an adverse effect on in-household water contamination, larger in effect size than the mitigation effect of access to sanitation or personal hygiene. To control transmission of fecal pathogens, effective barriers are required for wastewater irrigation similar to the necessity of ensuring access to sanitation and practicing adequate hygiene behavior.

Place identity, autobiographical memory and life path trajectories: The development of a place-time-identity model

The ability to remember, recognize and reconstruct places is a key component of episodic autobiographical memory. In this respect, place forms an essential basis for the unfolding of experiences in memory and imagination. The autobiographical memory is seen to contribute to a sense of self and place identity. The aim of this study was to concertedly analyze paintings, autobiographical narrations and places of birth and life of clients under treatment at a psychiatric clinic in Switzerland who were manifesting psychiatric disorders, e.g. depression, anxiety disorders, bipolar disorder, personality disorder, substance dependence, and dementia. Each client exhibited distinctive attitudes and approaches towards life characterized by unique personal mental constructs for living in given places of time episodes that worked towards shaping the development of their identities as well as the development of their health. For these clients, place and time function together to leave a mark, a trajectory, that can hinder or help the resolution of a psychiatric condition. Based on six representative cases, we illustrate how each painting, each biographical narration and each interview reveals deeper structures of individual perception, emotions, feelings, coping strategies, and capacities to reflect and identify with place-time trajectories. Based on this analysis, a place-time-identity model has been developed, which emphasizes the importance of narration, the structure of personality, and emotional experiences in the development of the 'relay station' of episodic autobiographical memory, self and autonoetic consciousness: these three elements are not only connected through their embeddedness in time, but also through their embeddedness in place. In this context, place provides an external fundus of memory, capable of supporting humans in healthy recollection and remembering. The process of placing appears to contribute to the creation of self-esteem and identity. This psycho-geographical place-life-time approach is contrasted to phenomenological place-space-time theories of Husserl, Heidegger, Bachelard, and Sloterdijk.

The impact of water on health and ill-health in a sub-Saharan African wetland: Exploring both sides of the coin

Wetlands are a source of water out of which humans derive their livelihoods in Sub-Saharan Africa. They are often over-utilized and expose humans to disease-causing infectious agents. This calls for an evaluation of the role of water, sanitation and hygiene (WASH) and their effects in disease prevention and transmission in wetlands. A health risk assessment based on syndromic surveillance of self-reported abdominal complaints and fever gathered from a rural wetland in semiarid Kenya is presented with symptoms serving as proxies for real health threats in wetlands. The incidence of abdominal complaints was significantly higher for those using unimproved water sources compared to improved water users (odds ratio 7.5; 95% CI 2.59-26.9; p=0.001). Drainage of stagnant water near the house (odds ratio 0.2; 95% CI 0.08-0.54; p=0.002) and sanitary hygiene (odds ratio 0.4; 95% CI 0.71-0.97; p=0.056) were associated with reduced risk of abdominal complaints. Drainage of water was also associated with reduced risk of fever (odds ratio 0.3; 95% CI 0.02-0.59; p=0.002) and so was the use of mosquito nets (odds ratio 0.6; 95% CI 0.39-0.02; p=0.063). Usage of wetlands in the afternoon, e.g. for irrigated agriculture, increased the incidence of fever (odds ratio 1.5; 95% CI 0.91-2.33; p=0.040). Overall, there appears a greater likelihood of reducing pathogen exposure in the domestic than in the occupational domain or in the proximity to the wetland. We show that WASH, environmental hygiene and human behaviour are risk factors associated with the contraction of diseases characterized by abdominal complaints (e.g. diarrhoea) and fever (e.g. malaria) in wetlands. The same factors also have the potential to promote human health in the context of wetlands. We demonstrate the applicability of syndromic approaches in surveillance-scarce areas and emphasize the importance of adopting an integrated health-based wetland management that considers WASH and incorporates strategies based on grassroots level risk assessments.

Contracting infectious diseases in Sub-Saharan African wetlands: A question of use? A review

Worldwide the pressure on water is increasing. In parts of Sub-Saharan Africa (SSA), natural wetlands constitute the only accessible water resources, providing water free of charge, agricultural potential and livelihoods in otherwise uninhabitable landscapes, which is why they are being used extensively. The degradation and contamination of water which result from the use of wetlands has the potential to spread disease-causing microorganisms and provide increased breeding habitats for disease vectors, Despite this importance, case studies are lacking and knowledge gaps remain about whether and how different kinds of wetland use influence the exposure to health risks and transmission of infectious diseases. This descriptive literature review aimed at identifying publications from peer-reviewed journals and book chapters that (i) address water-related infectious diseases in SSA wetlands and (ii) link those diseases to use-related exposures. The resulting overview includes 27 publications and shows that depending on the type of use, people in wetlands are exposed to different risk factors and water-related infectious diseases. Exposure to infectious agents depends on occupational characteristics, and time spent in wetlands. Disease transmission is driven by users' contact to water, characteristics of pathogens and vectors of disease. The amount of available literature varies significantly. Whereas several publications have linked crop production and the domestic use of wetland water to contraction of diseases, fewer are available on health risks identified with pastoralism in wetlands and other uses. Some risk factors are well researched, such as irrigation schemes favouring schistosomiasis prevalence. For others, including proximity of pastoralists to their livestock and the associated trachoma risk, knowledge remains limited. This review establishes connections of selected diseases with different transmission pathways that are linked to specific risk factors, transmission pathways and resulting diseases. All of these have been integrated into a detailed conceptual framework which simplifies the complexity of the relationships, while at the same time identifying missing links which might provide stimulus for future research tackling the potential research gaps. It concludes that socio-cultural and behavioural considerations regarding the wetland users are not sufficiently evaluated and should receive increased attention in future investigations.

Developing the urban blue: Comparative health responses to blue and green urban open spaces in Germany

Recently, new perspectives upon healthy urban open spaces propose that open spaces can be regarded as urban green or blue spaces. However, there has so far been very little research into blue environments and their benefits for mental well-being. Our article focuses on the effects of water in cities, "urban blue" (as compared to "urban green"), on human health and well-being. To assess the mental well-being of visitors, we conducted qualitative semi-standardised interviews (n=113), asking which differences in well-being occur when visiting urban green and blue spaces in high-density areas of the inner city in Dusseldorf and Cologne, Germany. Although we found many similarities, some health-enhancing effects for users turned out to be prominent for urban blue in the four conceptual therapeutic landscape dimensions: experienced, symbolic, social and activity space. These effects include enhanced contemplation, emotional bonding, participation, and physical activity. The results suggest that urban blue as a health-promoting factor needs more detailed and accurate determination and examination of its general and local health-enhancing effects.

Applying QMRA and DALY to assess health risks from river bathing

To estimate the health impact of bathing in urban river waters a two-step risk assessment was conducted using the example of the Ruhr River in North-Rhine Westphalia (Germany). The risk of acquiring gastrointestinal illness (GI) due to bathing in the Ruhr River was the focus of this analysis. Referring to the WHO guidelines for safe recreational water environments, risk was defined as the probability of occurrence x severity of harm. Thus, the probability of acquiring GI by bathing in the Ruhr River has been calculated by means of the quantitative microbial risk assessment (QMRA) method. Additionally to this, harm was operationalized by using the DALY metric, quantifying the impact of disability for public health. The calculation of the DALYs based on the QMRA results, disease and lethality data of the population, duration of diseases, disability weights and a demographic profile of a regionally determined potential bathing population. DALYs were calculated for norovirus gastroenteritis, rotavirus gastroenteritis, cryptosporidiosis and giardiasis. The calculated DALYs were set into relation to other risks of daily life. Furthermore the effect of age weighting and time discounting for this site-specific population was considered. The viral load caused the main part of the environmental burden of disease by bathing in the river. The calculated DALYs are significantly lower than DALYs for all cause GI in Germany, which reach 1.19 DALY/1000, or DALYs accepted for an official EG designated bathing water (2.579 DALYs/1000 persons) but on a comparable level with the DALY for drowning (0.26 DALY/1000 Persons). The DALY concept provides a complementary tool to the QMRA for evaluating and comparing health risks arising from a specific environment for a specific population and behaviour and for comparing with other health risks of daily life.

Post-industrial river water quality-Fit for bathing again?

For the Ruhr River, bathing has been prohibited for decades. However, along with significant improvements of the hygienic water quality, there is an increasing demand of using the river for recreational purposes, in particular for bathing. In the "Safe Ruhr" interdisciplinary research project, demands, options and chances for lifting the bathing ban for the Ruhr River were investigated. As being the prominent reason for persisting recreational restrictions, microbiological water quality was in the focus of interest. Not only the faecal indicator organisms (FIOs) as required by the European Bathing Water Directive were considered, but also pathogens such as Salmonella, Pseudomonas aeruginosa, Legionella pneumophila, Campylobacter, Leptospira, enteroviruses and protozoan parasites. In this introductory paper, we firstly relate current recreational desires to historical experiences of river bathing. After recapitulating relevant microbial river contamination sources (predominantly sewage treatment plants, combined sewer overflows, and surface runoffs), we review existing knowledge about the relationships of FIOs and pathogens in rivers designated for recreational purposes, and then trace the evolution, rationale and validity of recreational freshwater quality criteria which are, despite obvious uncertainties, mostly relying on the FIO paradigm. In particular, the representativeness of FIOs is critically discussed. The working programme of Safe Ruhr, aiming at initiating and facilitating a process towards legalisation of Ruhr River bathing, is outlined. Sources of contamination can be technically handled which leaves the actual measures to political decisions. As contaminations are transient, only occasionally exceeding legal limits, a flexible bathing site management, warning bathers of non-safe situations, may amend technical interventions and offer innovative solutions. As a result, a situation-adapted system for lifting of the bathing ban for Ruhr River appears realistic.

Water, sanitation and hygiene in wetlands. A case study from the Ewaso Narok Swamp, Kenya

Wetlands can be both a blessing and a curse. They are beneficial sources of safe water and nutrition and places from which humans derive their livelihoods. At the same time, wetlands are known to be sources of disease-causing microorganisms and invertebrates that can threaten human health. Safe water, sanitation and personal hygiene (WASH) are crucial preconditions for the prevention of disease transmission. And of special importance for people living in wetlands, depending on and being exposed to them. WASH should be prioritized especially in those wetlands that are subject to intensive use, that have a poor sanitation infrastructure, and which at the same time only provide limited water resources. However, despite this critical importance, WASH in wetlands is not well characterized in literature. This study therefore aimed at providing insights into the water, sanitation and hygiene conditions and behavioural determinants of households in wetlands by presenting the case of a rural wetland in East Africa. The mixed method approach included a broad set of empirical data collected during a household survey (n=400), an observational WASH assessment (n=397) and in-depth interviews (n=20) conducted from January to March 2015 in Ewaso Narok Swamp in Kenya. Different user groups of the wetland were targeted. The study in Ewaso Narok Swamp showed that wetland users' water supply and storage, sanitation and personal hygiene conditions were inadequate for large parts of the community and significantly differed between groups. Whereas the WASH conditions of people working in the service sector were rather positive, for pastoralists, they were correspondingly negative. The WASH behaviour was also perceived to be inadequate influenced by a variety of determining factors. The observational index as applied in this study indicated to be a valuable, rapid and efficient tool for assessing domestic WASH and for detecting differences between different groups in wetlands. Combined with the quantitative and qualitative data, the approach served as a very helpful model to develop a multi-layered understanding of WASH conditions and related behaviour. The people in the researched wetland use by far less improved water sources and sanitation facilities than the nationwide average for rural populations. Since Ewaso Narok Swamp serves as a model case for the domestic WASH conditions in a rural wetland in semiarid East Africa, this fact make the study relevant not only at a national, but also at an international level. The results underline the previously formulated need of an integrative approach that first and foremost complements wetland management by public health interventions. In order to improve WASH conditions and to change behaviour in the long term, interventions should include the provision of clean water and sanitation infrastructure, as well as widespread health education. The approach proved to be useful for wetland environments and will be integrated into the development of a health impact assessment tool for wetlands. Moreover, it can be adopted in other contexts.

[Identification of Systemic Contaminations with Legionella Spec. in Drinking Water Plumbing Systems: Sampling Strategies and Corresponding Parameters]

After the amendment of the Drinking Water Ordinance in 2011, the requirements for the hygienic-microbiological monitoring of drinking water installations have increased significantly. In the BMBF-funded project "Biofilm Management" (2010-2014), we examined the extent to which established sampling strategies in practice can uncover drinking water plumbing systems systemically colonized with Legionella. Moreover, we investigated additional parameters that might be suitable for detecting systemic contaminations. We subjected the drinking water plumbing systems of 8 buildings with known microbial contamination (Legionella) to an intensive hygienic-microbiological sampling with high spatial and temporal resolution. A total of 626 drinking hot water samples were analyzed with classical culture-based methods. In addition, comprehensive hygienic observations were conducted in each building and qualitative interviews with operators and users were applied. Collected tap-specific parameters were quantitatively analyzed by means of sensitivity and accuracy calculations. The systemic presence of Legionella in drinking water plumbing systems has a high spatial and temporal variability. Established sampling strategies were only partially suitable to detect long-term Legionella contaminations in practice. In particular, the sampling of hot water at the calorifier and circulation re-entrance showed little significance in terms of contamination events. To detect the systemic presence of Legionella,the parameters stagnation (qualitatively assessed) and temperature (compliance with the 5K-rule) showed better results.

Developing an easy-to-apply model for identifying relevant pathogen pathways into surface waters used for recreational purposes

Swimming in inner-city surface waters is popular in the warm season, but can have negative consequences such as gastro-intestinal, ear and skin infections. The pathogens causing these infections commonly enter surface waters via several point source discharges such as the effluents from wastewater treatment plants and sewer overflows, as well as through diffuse non-point sources such as surface runoff. Nonetheless, the recreational use of surface waters is attractive for residents. In order to save financial and organizational resources, local authorities need to estimate the most relevant pathways of pathogens into surface waters. In particular, when detailed data on a local scale are missing, this is quite difficult to achieve. For this reason, we have developed an easy-to-apply model using the example of Escherichia coli and intestinal enterococci as a first approach to the local situation, where missing data can be replaced by data from literature. The model was developed based on a case study of a river arm monitored in western Germany and will be generalized for future applications. Although the limits of the EU Bathing Water Directive are already fulfilled during dry weather days, we showed that the effluent of wastewater treatment plants and overland flow had the most relevant impact on the microbial surface water quality. On rainy weather days, combined sewer overflows are responsible for the highest microbial pollution loads. The results obtained in this study can help decision makers to focus on reducing the relevant pathogen sources within a catchment area.

Modelling characteristics to predict Legionella contamination risk - Surveillance of drinking water plumbing systems and identification of risk areas

For the surveillance of drinking water plumbing systems (DWPS) and the identification of risk factors, there is a need for an early estimation of the risk of Legionella contamination within a building, using efficient and assessable parameters to estimate hazards and to prioritize risks. The precision, accuracy and effectiveness of ways of estimating the risk of higher Legionella numbers (temperature, stagnation, pipe materials, etc.) have only rarely been empirically assessed in practice, although there is a broad consensus about the impact of these risk factors. We collected n = 807 drinking water samples from 9 buildings which had had Legionella spp. occurrences of >100 CFU/100mL within the last 12 months, and tested for Legionella spp., L. pneumophila, HPC 20°C and 36°C (culture-based). Each building was sampled for 6 months under standard operating conditions in the DWPS. We discovered high variability (up to 4 log(10) steps) in the presence of Legionella spp. (CFU/100 mL) within all buildings over a half year period as well as over the course of a day. Occurrences were significantly correlated with temperature, pipe length measures, and stagnation. Logistic regression modelling revealed three parameters (temperature after flushing until no significant changes in temperatures can be obtained, stagnation (low withdrawal, qualitatively assessed), pipe length proportion) to be the best predictors of Legionella contamination (>100 CFU/100 mL) at single outlets (precision = 66.7%; accuracy = 72.1%; F(0.5) score = 0.59).

Blue space geographies: Enabling health in place

Drawing from research on therapeutic landscapes and relationships between environment, health and wellbeing, we propose the idea of 'healthy blue space' as an important new development Complementing research on healthy green space, blue space is defined as; 'health-enabling places and spaces, where water is at the centre of a range of environments with identifiable potential for the promotion of human wellbeing'. Using theoretical ideas from emotional and relational geographies and critical understandings of salutogenesis, the value of blue space to health and wellbeing is recognised and evaluated. Six individual papers from five different countries consider how health can be enabled in mixed blue space settings. Four sub-themes; embodiment, inter-subjectivity, activity and meaning, document multiple experiences within a range of healthy blue spaces. Finally, we suggest a considerable research agenda - theoretical, methodological and applied - for future work within different forms of blue space. All are suggested as having public health policy relevance in social and public space.

Field testing hot water temperature reduction as an energy-saving measure--does the Legionella presence change in a clinic's plumbing system?

Legionella spp. represent a significant health risk for humans. To ensure hygienically safe drinking water, technical guidelines recommend a central potable water hot (PWH) supply temperature of at least 60°C at the calorifier. In a clinic building we monitored whether slightly lowered temperatures in the PWH system led to a systemic change in the growth of these pathogens. In four separate phases we tested different scenarios concerning PWH supply temperatures and disinfection with chlorine dioxide (ClO2). In each phase, we took 5 sets of samples at 17 representative sampling points in the building's drinking water plumbing system. In total we collected 476 samples from the PWH system. All samples were tested (culture-based) for Legionella spp. and serogroups. Additionally, quantitative parameters at each sampling point were collected, which could possibly be associated with the presence of Legionella spp. (Pseudomonas aeruginsoa, heterotrophic plate count at 20°C and 36°C, temperatures, time until constant temperatures were reached, and chlorine dioxide concentration). The presence of Legionella spp. showed no significant reactions after reducing the PWH supply temperature from 63°C to 60°C and 57°C, as long as disinfection with ClO2 was maintained. After omitting the disinfectant, the PWH system showed statistically significant growth rates at 57°C. PWH temperatures which are permanently lowered to less than recommended values should be carefully accompanied by frequent testing, a thorough evaluation of the building's drinking water plumbing system, and hygiene expertise.

The impact of flooding on people living with HIV: a case study from the Ohangwena Region, Namibia

BACKGROUND

Floods are a disaster situation for all affected populations and especially for vulnerable groups within communities such as children, orphans, women, and people with chronic diseases such as HIV and AIDS. They need functioning health care, sanitation and hygiene, safe water, and healthy food supply, and are critically dependent on their social care and support networks. A study carried out in the Ohangwena region, Namibia, where HIV prevalence is high and extensive flooding frequently occurs, aims to provide a deeper understanding of the impact that flooding has on people living with HIV (PLWHIV) as well as on HIV service providers in the region.

DESIGN

The qualitative research applying grounded theory included semi-structured interviews with PLWHIV, focus group discussions with HIV service providers, and a national feedback meeting. The findings were interpreted using the sustainable livelihoods framework, the natural hazard research approach, and health behaviour theories.

RESULTS

The study reveals that flooding poses major problems to PLWHIV in terms of their everyday lives, affecting livelihoods, work, income, and living conditions. The factors threatening them under normal conditions - poverty, malnutrition, unsafe water, sanitation and hygiene, limited access to health facilities, a weak health status, and stigma - are intensified by flood-related breakdown of infrastructure, insecurity, malnutrition, and diseases evolving over the course of a flood. A potential dual risk exists for their health: the increased risk both of infection and disease due to the inaccessibility of health services and antiretroviral treatment. A HIV and Flooding Framework was developed to display the results.

CONCLUSIONS

This study demonstrates that vulnerabilities and health risks of PLWHIV will increase in a disaster situation like flooding if access to HIV prevention, treatment, care and support are not addressed and ensured. The findings and the HIV and Flooding Framework are not specific to Ohangwena and can be transferred to any flood-affected region that has a high HIV prevalence and relies mainly on subsistence agriculture. They serve as a model case for analysing vulnerabilities related to health and health service provision under disaster conditions. The impact will vary according to the physical, geographical, climatological, social, and behavioural characteristics of the region and the people affected. In the Ohangwena region, a disaster risk management mechanism is already in place which addresses people with HIV during flooding. However, preparedness could be improved further by applying the HIV and Flooding Framework.

The impact of land use on microbial surface water pollution

Our knowledge relating to water contamination from point and diffuse sources has increased in recent years and there have been many studies undertaken focusing on effluent from sewage plants or combined sewer overflows. However, there is still only a limited amount of microbial data on non-point sources leading to diffuse pollution of surface waters. In this study, the concentrations of several indicator micro-organisms and pathogens in the upper reaches of a river system were examined over a period of 16 months. In addition to bacteria, diffuse pollution caused by Giardia lamblia and Cryptosporidium spp. was analysed. A single land use type predestined to cause high concentrations of all microbial parameters could not be identified. The influence of different land use types varies between microbial species. The microbial concentration in river water cannot be explained by stable non-point effluent concentrations from different land use types. There is variation in the ranking of the potential of different land use types resulting in surface water contamination with regard to minimum, median and maximum effects. These differences between median and maximum impact indicate that small-scale events like spreading manure substantially influence the general contamination potential of a land use type and may cause increasing micro-organism concentrations in the river water by mobilisation during the next rainfall event.

Retention of pharmaceutical residues and microorganisms at the Altendorf retention soil filter

A study has been conducted on a retention soil filter (RSF) to test its effectiveness in removing pharmaceutical residues and microorganisms from combined sewer overflows (CSOs). Efficient removal of solids, nutrients and heavy metals has already been proven. The possibility that organic micropollutants and microorganisms are also retained by the use of RSFs has been identified, but data are lacking. Results obtained in this study, in which testing for removal by a RSF of numerous micro-pollutant substances was performed, are most promising. The pharmaceuticals diclofenac and ibuprofen are presented in detail as examples of such micropollutants. Both showed a reduction in positive samples of more than 55% as well as a significant reduction in median and maximum concentrations. For microorganisms such as Escherichia coli, coliphages and Giardia lamblia (cysts), an average reduction in concentrations by three logarithmic steps (99.9%) was achieved. These results add to the evidence that using a RSF in the advanced treatment of wastewater from CSOs reduces the exposure of water-courses to pharmaceutical residues and microbial contamination.

Antibiotic resistance among autochthonous aquatic environmental bacteria

Antibiotics are widely used in both human and veterinary medicine and antibiotic-resistant bacteria cause problems in antibiotic therapy. The current study was conducted in the catchment area of the river Swist (Germany) and focuses on the resistance of environmental Rhodospirillaceae to antibiotics used in human medicine. The samples collected reflect different levels of human impact on the environment. In total, 614 isolates were tested for antibiotic susceptibility. About half of these isolates were susceptible to all substances tested. Oxacillin resistance was observed most frequently (41%). Resistant Rhodospirillaceae were detected in wastewater effluent from a municipal sewage treatment plant, as well as in non-polluted upper reaches. The highest multi-resistance level was detected in small tributaries and it surprisingly decreased with an increasing influence of municipal wastewater. It could be shown that the detected resistances were acquired rather than intrinsic. Besides natural occurrence of multi-resistance among non-sulphur purple bacteria, horizontal gene transfer and acquired cross-resistance against veterinary antibiotics are assumed to be important factors. To the authors' knowledge, this is the first study investigating the potential of Rhodospirillaceae as a reservoir for resistance to antibiotics used in human medicine. The consequence for resistance prevalence in human pathogens and for their antibiotic therapy needs evaluation.

Climate Change Impact Assessment of Food- and Waterborne Diseases

The PubMed and ScienceDirect bibliographic databases were searched for the period of 1998-2009 to evaluate the impact of climatic and environmental determinants on food- and waterborne diseases. The authors assessed 1,642 short and concise sentences (key facts), which were extracted from 722 relevant articles and stored in a climate change knowledge base. Key facts pertaining to temperature, precipitation, water, and food for 6 selected pathogens were scrutinized, evaluated, and compiled according to exposure pathways. These key facts (corresponding to approximately 50,000 words) were mapped to 275 terminology terms identified in the literature, which generated 6,341 connections. These relationships were plotted on semantic network maps to examine the interconnections between variables. The risk of campylobacteriosis is associated with mean weekly temperatures, although this link is shown more strongly in the literature relating to salmonellosis. Irregular and severe rain events are associated with Cryptosporidium sp. outbreaks, while noncholera Vibrio sp. displays increased growth rates in coastal waters during hot summers. In contrast, for Norovirus and Listeria sp. the association with climatic variables was relatively weak, but much stronger for food determinants. Electronic data mining to assess the impact of climate change on food- and waterborne diseases assured a methodical appraisal of the field. This climate change knowledge base can support national climate change vulnerability, impact, and adaptation assessments and facilitate the management of future threats from infectious diseases. In the light of diminishing resources for public health this approach can help balance different climate change adaptation options.

Knowledge Mapping for Climate Change and Food- and Waterborne Diseases

The authors extracted from the PubMed and ScienceDirect bibliographic databases all articles published between 1998 and 2009 that were relevant to climate change and food- and waterborne diseases. Any material within each article that provided information about a relevant pathogen and its relationship with climate and climate change was summarized as a key fact, entered into a relational knowledge base, and tagged with the terminology (predefined terms) used in the field. These terms were organized, quantified, and mapped according to predefined hierarchical categories. For noncholera Vibrio sp. and Cryptosporidium sp., data on climatic and environmental influences (52% and 49% of the total number of key facts, respectively) pertained to specific weather phenomena (as opposed to climate change phenomena) and environmental determinants, whereas information on the potential effects of food-related determinants that might be related to climate or climate change were virtually absent. This proportion was lower for the other pathogens studied (Campylobacter sp. 40%, Salmonella sp. 27%, Norovirus 25%, Listeria sp. 8%), but they all displayed a distinct concentration of information on general food-and water-related determinants or effects, albeit with little detail. Almost no information was available concerning the potential effects of changes in climatic variables on the pathogens evaluated, such as changes in air or water temperature, precipitation, humidity, UV radiation, wind, cloud coverage, sunshine hours, or seasonality. Frequency profiles revealed an abundance of data on weather and food-specific determinants, but also exposed extensive data deficiencies, particularly with regard to the potential effects of climate change on the pathogens evaluated. A reprioritization of public health research is warranted to ensure that funding is dedicated to explicitly studying the effects of changes in climate variables on food- and waterborne diseases.