A review on the 40th anniversary of the first regulation of drinking water disinfection by-products

Water disinfection, primarily by chlorination, is one of the greatest achievements of public health. However, more than half a century after its introduction, studies in the 1970s reported that (a) chlorine interacted with organic matter in the water to form disinfection by-products (DBPs); (b) two DBPs, chloroform and bromoform, both trihalomethanes (THMs), were rodent carcinogens; (c) three brominated THMs were mutagenic; in six studies chlorinated drinking waters in the United States and Canada were mutagenic; and (d) in one epidemiological study there was an association between bladder cancer mortality and THM exposure. This led the U.S. Environmental Protection Agency to issue its first DBP regulation in 1979. Forty years later, >600 DBPs have been characterized, 20/22 have been shown to be rodent carcinogens, >100 have been shown to be genotoxic, and 1000s of water samples have been found to be mutagenic. Data support a hypothesis that long-term dermal/inhalation exposure to certain levels of the three brominated THMs, as well as oral exposure to the haloacetic acids, combined with a specific genotype may increase the risk for bladder cancer for a small but significant population group. Improved water-treatment methods and stricter regulations have likely reduced such risks over the years, and further reductions in potential risk are anticipated with the application of advanced water-treatment methods and wider application of drinking water regulations. This 40-year research effort is a remarkable example of sustained cooperation between academic and government scientists, along with public/private water companies, to find answers to a pressing public health question.

Don't Shut the Stable Door after the Phage Has Bolted-The Importance of Bacteriophage Inactivation in Food Environments

In recent years, a new potential measure against foodborne pathogenic bacteria was rediscovered-bacteriophages. However, despite all their advantages, in connection to their widespread application in the food industry, negative consequences such as an uncontrolled phage spread as well as a development of phage resistant bacteria can occur. These problems are mostly a result of long-term persistence of phages in the food production environment. As this topic has been neglected so far, this article reviews the current knowledge regarding the effectiveness of disinfectant strategies for phage inactivation and removal. For this purpose, the main commercial phage products, as well as their application fields are first discussed in terms of applicable inactivation strategies and legal regulations. Secondly, an overview of the effectiveness of disinfectants for bacteriophage inactivation in general and commercial phages in particular is given. Finally, this review outlines a possible strategy for users of commercial phage products in order to improve the effectiveness of phage inactivation and removal after application.

Regulated and emerging disinfection by-products in recycled waters

Disinfection is an integral component of water treatment performed daily on large volumes of water worldwide. Chemical disinfection may result in the unintended production of disinfectant by-products (DBPs) due to reactions between disinfectants and natural organic matter present in the source water. Due to their potential toxicity, levels of DBPs have been strictly regulated in drinking waters for many years. With water reuse now becoming more common around the world DBPs are increasingly becoming a concern in recycled waters, where a much larger amount and variety of compounds may be formed due to a higher abundance and diversity of organic material in the source waters. Regulation of DBPs in recycled waters is limited; generally, drinking water regulations are applied in place of specific guidelines for recycled waters. Such regulations are set for only 11, commonly observed, compounds of the 600+ that may, potentially, be found. In this review an overview of current research in this area is provided, the types of compounds that have been observed, methods for their analysis and possible regulation are also discussed. Through this review it is evident that there is a knowledge gap for the occurrence of DBPs in recycled waters, especially when comparing this information to that available for drinking waters. The concentrations of DBPs observed in recycled waters are seen to be higher than those in drinking water, though still within potable threshold limits. It is clear that there is a need for the analysis and understanding of a larger suite of compounds in recycled waters, as these will most likely be the source of future, global renewable water.

Development of recreational water spray ground design regulations in New York State, an engineering approach

The New York State Department of Health developed regulations for the design and operation of spray grounds to address the potential for recreational water illnesses associated with this type of venue. The water treatment component of the new regulation was based on a first-principles approach to address the unique challenges of spray grounds. The regulation departs from traditional recreational water treatment methods by requiring a novel filtration approach and the installation of UV disinfection. The water treatment system was also required to incorporate automatic control systems to ensure the water quality is maintained with a minimum of operator involvement. The treatment process specifications were based on pathogen and contaminant loadings that are likely to be encountered at spray grounds. The regulation was finalized in 2007, giving New York State a reliable means of protecting the health of spray ground patrons.

Limiting swimming pool outbreaks of cryptosporidiosis - the roles of regulations, staff, patrons and research

Cryptosporidium is the leading cause of swimming pool outbreaks of gastroenteritis. Transmission occurs through the ingestion of oocysts that are passed in the faeces of an infected person or animal when an accidental faecal release event occurs. Cryptosporidium parasites present specific challenges for infection control as oocysts are highly resistant to chlorine levels used for pool disinfection, infected individuals can shed large numbers of oocysts, there is a long incubation period and shedding of oocysts occurs even after symptom resolution. The purposes of this review are to identify key barriers to limiting swimming pool-associated outbreaks of cryptosporidiosis and to outline needs for research and collaboration to advance co-ordinated management practices. We reviewed swimming pool-associated cryptosporidiosis outbreaks, disinfection teachniques, current regulations and the role of staff and patrons. Key barriers to limiting swimming pool-associated outbreaks of cryptosporidiosis are a lack of uniform national and international standards, poor adherence and understanding of regulations governing staff and patron behaviour, and low levels of public knowledge and awareness.

Disinfection in the laboratory: theory and practice in disinfection policy in late C19th and early C20th England

This article examines the relationship between theory and practice in nineteenth century English public health disinfection practice. Disinfection undertaken by local authorities and practised on objects, spaces and people became an increasingly common public health practice in the last quarter of the nineteenth century, and was part of a newly developed public health system of 'stamping out' disease as described by Hardy. Despite disinfection's key role in public health policy, it has thus far not received significant investigation or historiographical attending. This article explores the development of disinfection policy at local level, highlighting that despite commentators assumptions that increasingly exacting standards of disinfection required professional oversight rather than that of the 'amateur' public, there was a significant gap between laboratory based knowledge and evidence derived from practical experience. Laboratory conditions could not replicate those found in day-to-day disinfection, and there were myriad debates about how to create a mutually understandable scientific standard for testing. Despite increasing efforts to bring local disinfection in line with new ideas promulgated by central government and disinfection researchers, the mismatches between the two meant that there was greater divergence. This tension lay at the heart of the changes in disinfection theory and practice in the second half of the nineteenth century, and illustrate the complexities of the impact of germ theory on public health policy.

Antifouling strategies: history and regulation, ecological impacts and mitigation

Biofouling increases drag on marine vessels resulting in higher fuel consumption and can also facilitate the transport of harmful non-indigenous species (NIS). Antifouling technologies incorporating biocides (e.g., copper and tributyltin) have been developed to prevent settlement of organisms on vessels, but their widespread use has introduced high levels of contamination into the environment and raised concerns about their toxic effects on marine communities. The recent global ban on tributyltin (1 January 2008) and increasing regulation of copper have prompted research and development of non-toxic paints. This review synthesises existing information regarding the ecological impact of biocides in a wide range of organisms and highlights directions for the management of antifouling paints. We focus particularly on representatives of the recent past (copper and tributyltin) and present (copper and 'booster') biocides. We identify knowledge gaps in antifouling research and provide recommendations relating to the regulation and phasing-out of copper.

Prevention of Salmonella enteritidis in shell eggs during production, storage, and transportation. Final rule

The Food and Drug Administration (FDA) is issuing a final rule that requires shell egg producers to implement measures to prevent Salmonella Enteritidis (SE) from contaminating eggs on the farm and from further growth during storage and transportation, and requires these producers to maintain records concerning their compliance with the rule and to register with FDA. FDA is taking this action because SE is among the leading bacterial causes of foodborne illness in the United States, and shell eggs are a primary source of human SE infections. The final rule will reduce SE-associated illnesses and deaths by reducing the risk that shell eggs are contaminated with SE.

Ozone disinfection with the HiPOX reactor: streamlining an old technology for wastewater reuse

Although ozone disinfection is a well established technology for drinking water treatment, ozone disinfection mechanisms in wastewater are not well understood such that, historically, ozone wastewater disinfection has not been a feasible technology to implement. The HiPOx system is an ozone-based pressurized in-vessel system that can be used either as an advanced oxidation reactor or as a highly efficient ozone dissolution system. The pilot-scale HiPOx system was temporarily installed at the Dublin San Ramon Services District (DSRSD) Wastewater Treatment Plant in Dublin, California. Detailed bioassay testing was conducted on the pilot reactor between October and December 2007. Tests on benchtop reactors were performed in June and August 2007. Pilot tests on the HiPOx reactor located at DSRSD showed that 6.5 log removal of MS2 coliphage was observed at conservative transferred ozone doses of 5 mg/L (contact time of 93 seconds) in microfiltered water, and 7 mg/L (contact time of 50 seconds) in media filtered water. In media filtered water, minimum CT values of 1.0 mg-min/L resulted in non detect total coliform.

[The principle of registration, evaluation and testing of disinfecting preparations]

Disinfectants are used to produce a state in which the number of living micro-organisms has been reduced to a level which is appropriate to the practical situation. For any products which are included in the Biocidal Directive 98/8/EC, for which specific activity is claimed, test data has to be approved by the regulatory authority and a product license obtained before the product can be offered for sale. Disinfectants can be recorded as biocidal products or medical devices. Presently, it is possible to measure the activity of a product on defined micro-organisms in specified experimental conditions. Efficacy is the result of the use of a product according to a defined application. To allow different requirements in different areas of application, separate tests and pass criteria have been or will be prepared for each of following three areas of application: medical, veterinary and group comprising food, industrial, domestic and institutional areas. The laboratory methods to be used for testing the activity of chemical disinfectants meets the European standards. The tests are categorised on a modular basis as follows: phase 1 tests, phase 2 step 1 tests, phase 2 step 2 tests and phase 3 tests. In order to claim that a product has disinfectant properties, suitable for use in the medical area, the product shall be tested according to European standards: phase 2 step 1 tests, phase 2 step 2 tests. Phase 1 tests are not required to support claims for chemical disinfectants used in human medicine. Only phase 1 tests are required to support claims for active substances for which no particular area of application is specified. Medical devices are subjects to the European Directive 93/42/EEC which requires that a product must carry a CE mark. Disinfectants which are intended specifically by its manufacturer to be used on medical devices are themselves medical devices and so these products, as well as conforming to the instrument disinfection European standards as specified in EN 14885, are also required to carry a CE mark.

[Applicability of the new law of State and Regional Agreement on management of swimming pools]

The Authors carried out a survey on private and public managers of 80 Italian swimming pools to evaluate the hygienic aspects and safety of the swimming pools. Participants were submitted to a set of questions about the modifications recently brought to the Act on management of the swimming pools during 2003. The study showed a poor knowledge about the hygienic-safety parameters, in particular of chlorine doses, range of temperature and frequency of daily turnover of the swimming pool water. The respect of chemical-physical parameters is necessary not only to assure an adequate microbial control of the water, but also to reduce the production of irritant and potentially toxic substances. The Authors pointed out the need of greater attention to hygienic aspects in order to reduce health risks, deriving from an uncorrected application of the laws, and to provide a greater comfort to the users of swimming pools.

[Guidelines for the organization and management of disinfection and disinfestation from rodents and mosquitoes]

Two recent legislative acts (D.P.C.M. 29.11.2001 and D.G.R. Veneto n. 2093, issued 02.08.2002) give to Local Health Authorities responsibility over surveillance of disinfestations activities. Authority over the implementation of these actions remains with the municipalities. Another legislative act (D.G.R. Veneto 3015) established the creation of a task force in order to define guidelines regarding new managerial methods toward disinfections, disinfestations and rodent control for public administration. The "Guidelines for the organization and management of disinfection and of rodent and mosquito control" redefine the roles for the public administration units involved, propose a new organizational model and an innovative managerial approach to activities, provides technical recommendations for the preparation of specific contracts and for the implementation of disinfestation actions. Finally, the guidelines include a proposal for the development of regulations supporting the technical propositions.

Medicare and Medicaid programs; fire safety requirements for certain health care facilities; amendment. Interim final rule with comment period

This interim final rule with comment period adopts the substance of the April 15, 2004 temporary interim amendment (TIA) 00-1 (101), Alcohol Based Hand Rub Solutions, an amendment to the 2000 edition of the Life Safety Code, published by the National Fire Protection Association (NFPA). This amendment will allow certain health care facilities to place alcohol-based hand rub dispensers in egress corridors under specified conditions. This interim final rule with comment period also requires that nursing facilities install smoke detectors in resident rooms and public areas if they do not have a sprinkler system installed throughout the facility or a hard-wired smoke detection system in those areas.

The origins of the health defence system against contagious illness: the strategies of isolation and quarantine in Mediterranean cities from the XIV-XIX centuries

From the onset of the Black Death in 1347-48, Italian cities which faced the Mediterranean, an epidemic sea, constructed a complex and articulated health defence system which was an example to all other western countries. The cornerstones of this health defence system lay in quarantine, sanitary cordons, lazarets, disinfection, and in the social regulation of the population at risk. Medicine played no part. Its impotence in dealing with epidemic diseases left health defence to the initiative of the civil authorities who rigorously fought the repeated incursions of plague, which from the end of Middle Ages severely tried and tested social organisation, economic life and public order, all of which were threatened by reactions of fear and aggression. From the fifteenth century onwards the public authorities instituted health magistracies which perfected policing and hygiene strategies based on isolation, separation and social control. This progressively extended to individuals in the community through 'health certificates'. This paper follows the evolution and crises of the conceptual, cultural adn institutional response to epidemics through the centuries up to the appearance of the plague of cholera and its disappearance.

[Hygienic procedures in operation theatres--guidelines and reality. Data obtained on hygiene control measures by public health service at Frankfurt am Main]

PROBLEM

Good hygienic practice in hospitals and other medical institutions is mandatory to avoid or to minimise nosocomial infections. In Germany, official recommendations of the commission for hospital hygiene and infection control have been published as guidelines for hygiene management in hospitals as well as guidelines for control measures of the public health services who are obliged by law to control the hygienic situation in hospitals. In this paper the degree of implementation of these guidelines in the hospitals is studied in respect of the hygiene management in the operation theatre.

MATERIAL AND METHOD

The constructive and functional situation and the personal hygienic management were documented in 22 community and private hospitals in Frankfurt am Main, including 40 operation suites with 111 operation theatres. Data of the layout of the rooms were obtained by questionnaire and the hygienic management was observed by means of standardised checklists.

RESULTS

Layout of rooms was not compatible with the recommendations of the Guidelines of 1990 and 2000 in many cases--especially with regard to the demand that doors to the operating theatres be closed. Automatic door closers were often either not available or defective. In some theatre areas correct hand disinfection while entering the suite was not possible for lack of disinfectant distributors at appropriate sites. Recommendations regarding surgical drapes and gowns were correctly observed in most cases, with the exception of changing gowns after having gone to the toilet room. Quite often, omission of hand disinfection after glove removal was observed. A discrepancy in hygienic procedures of nursing service and physicians was seen. In 40 % of the operation suites, powdered gloves were still in use. Though in all but one suite air conditioning systems were available, they were not correctly serviced in many cases. Cleaning and disinfection after single operations and at the end of the operating day were carried out correctly in most cases--except in operation theatres for ophthalmologic operations. Here too, manual preparation and disinfection/sterilisation of surgical instruments was common, and inappropriate use of sterilisers as well as the use of so-called "quick"-sterilisers.

CONCLUSIONS

The recommendations of the commission for hospital hygiene and infection prevention are generally accepted as guidelines, although the degree of translation into practice was often unsatisfactory.

Medical devices; classification for medical washer and medical washer-disinfector. Final rule

The Food and Drug Administration (FDA) is classifying the medical washer and medical washer-disinfector intended for general medical purposes to clean and dry surgical instruments, decontaminate or disinfect anesthesia equipment, hollowware, and other medical devices into class II (special controls). FDA is also identifying the guidance document entitled "Class II Special Controls Guidance Document: Medical Washers and Medical Washer-Disinfectors" (the guidance) as the special control that, in addition to general controls, the agency believes will reasonably ensure the safety and effectiveness of the device. This action is being taken under the Federal Food, Drug, and Cosmetic Act (the act), as amended by the Medical Device Amendments of 1976 (the 1976 amendments), the Safe Medical Devices Act of 1990 (the SMDA), and the Food and Drug Administration Modernization Act of 1997 (the FDAMA).

[Survey of disinfectant usage in a polyclinic in Rome: preliminary results]

The authors describe the survey that was conducted in the largest hospital in Rome. The aim was to estimate the disinfectants and chemical sterilizers employed and asses possible hazards for patients and workers arising from the use of disinfectants, together with the problem of waste disposal. The study was conducted by means of a survey form that was distributed to 39 departments/institute in the whole hospital of which 24 (61%) responded. Overall 635 charts were collected listing 886 usage procedures and 110 formulations with 40 different active ingredients. The disinfection fields of use were: skin(52.4%) environment (28.8%) and hospital equipment (20.8%) This study shows that a modern hospital should select very few disinfectants and prepare a handbook that can explain disinfectant usage procedures and concentrations. In the guidelines the problem of waste disposal and employee safety should also be considered.

[Public health in homes for the aged and nursing homes--experiences from monitoring by the public health office in Frankfurt am Main from 1989 to 1998]

Hygiene conditions in residential homes for the aged must be surveyed by the Public Health services according to German legislation (Bundesseuchengesetz, Law for Protection against Infectious Diseases). We report here on the data of the routine controls of the public health department in Frankfurt am Main in all of the 31 residential homes for the aged of the city.

RESULTS

In 1989, a special plan for cleaning and disinfection was available in one home only, whereas a hygiene plan was not available in any of the homes. Up to 1998, plans for cleaning and disinfection were established in 29 of the homes, and more than 50% of them had fulfilled their hygiene plan. The supply and maintenance of dispersers for disinfectants, the usage of disinfectants and the knowledge regarding proper disinfection and sterilisation procedures could be improved. The same was true of the kitchens: there, up to 1998 testing of samples set aside for later reassessment was properly done in most of the homes.

CONCLUSION

Hygiene in the homes and the knowledge of the staff members were markedly improved during the last years. Some of the most relevant hygienic problems are today: wearing private clothing instead of special working clothes, or deficits in the knowledge of the management of MRSA-colonised residents.

[Regulatory aspects of disinfection of endoscopes]

The circular on the sterilization and the law of july 1, 1998 enact clearly that the medical devices that support steam sterilization must be sterilized with an organization of sterilization that ensure quality. Endoscope that enter normally sterile tissues should be subjected to a sterilization procedure before each use; if this is not feasible, they should receive high-level disinfection to destroy bacterial spores. The endoscope must be immersed for at least one hour in aqueous solution of 2% glutaraldehyde. This lengthened duration of processing must be integrate in the organization of medical department. The endoscopes not penetrating in a sterile cavity are disinfected with manual processing according to the protocol of the circular of april 1996, or with automated endoscope reprocessing machine. The different types of automated machine used to wash and disinfect endoscope must now answer to criterion concerning their design described in the circular of july 15, 1998. A significant work has to be made in hospitals to conform automated machine and procedure, to control the risk dependent with their use.

[Infection control monitoring of physician practices with approval according to section 218 StGB of the public health office. A discussion contribution to the planned infection control law (E-IFSG)]

Public Health authorities in Germany are obliged to check on the hygienic situation in hospitals, homes for the elderly, etc., but are not permitted to perform routine hygiene controls in physician's practices--with the exception of those that are licensed for termination of pregnancy (the latter exception applies to the Federal Land of Hesse). Public Health authorities in Frankfurt/Main have been checking on hygienic conditions in 16 medical practices in Frankfurt since 1990. Initially, severe hygienic defects were found. For example, in only one practice did they find a plan for safeguarding hygienic conditions, or a dispenser for disinfectants. Severe faults in disinfection and sterilisation methods or in handling medicaments, ampoules etc. were seen in many practices. However, in the course of years remarkable improvements have been achieved. These data support the official plan according to which Public Health authorities will be obliged to check on hygienic conditions prevailing also in the consulting rooms of practising specialists.

Hospital waste--the current and future treatment and disposal trends

Hospital wastes pose a serious public health problem. This is primarily caused by the diversity of the individual components of the waste which constitute a risk to health if inadequately handled. It is evident that economic and technical conditions for both a safe disposal, including environmentally sound manner incineration as well as efficient stem or microwave disinfection and a safe management practice based on legal regulations consequently will contribute to protections of both human health and the environment. There is no reason to assume there may be any universal, standard regulations to be used and accepted unianimously and consistently valid for all countries. It is necessary to honor the specific, social and economic background of every country. Nevertheless the European Community principles of hospital waste treatment and disposal will be eventually accepted by this country in principal, in the framework of a general economic and political integration of European countries.

Use of disinfectants in open-air dairying

Disinfection systems are essential in providing dairy foods which are safe for consumption by all sectors and age groups of the human population. The New Zealand dairy industry ensures quality competition under International Organisation for Standardisation (ISO) general systems standards (ISO 9002 and ISO Guide 25) and is subject to food safety assurance legislation (Dairy Industry Regulations 1990). This latter regulation requires that safe foods be produced in accordance with Product Safety Programmes approved by the Ministry of Agriculture and Fisheries. Safety can be demonstrated by compliance with the Codes of Practice of the industry. Farm dairy detergents and sanitisers must be approved for use. These disinfection systems are described.

Use of antimicrobial agents in official abattoirs under meat inspection in the United States of America

Facilities and equipment which are contaminated by a diseased carcass during slaughter and processing operations must be made free from microorganisms of human health concern before being used again. Therefore, a rapid-acting microbicidal agent is necessary to enable the swift resumption of operations. Currently, water heated to 180 degrees F (82.2 degrees C) is the antimicrobial agent of choice, as this rapidly kills microbes without leaving a residue which could jeopardize food products.

Cleaning and disinfection practice in the meat industries of Europe

The application and efficacy of cleaning and disinfection methods are reviewed, together with the relevant European and French legislation. European Commission Hygiene Directive 93/43/EEC of 14 June 1993 proposes the adoption of hazard analysis and critical control points (HACCP) for the meat industry, and this includes cleaning and disinfection. It is necessary to organise a team for washing, cleaning, rinsing, disinfection and final rinsing; three different types of organisation are compared. Application of HACCP and its contribution to the shelf life of products and their contamination with Listeria monocytogenes is discussed in the light of practical experience with poultry meat and cured pork products. Various means of verifying the efficacy of cleaning and disinfection (turbidimetry, adenosine triphosphate assay and macroscopic observation) are compared with the techniques of conventional microbiology. The authors conclude that cleaning and disinfection are essential for application of HACCP to the meat industry.

[Cleaning and disinfection of endoscopes in general practice and ambulatory care]

The legal conditions in Germany for cleaning and disinfection of endoscopes depend on the terms of reference of the "Bundesgesundheitsamt (BGA)" and the "Deutsche Gesellschaft für Hygiene und Mikrobiologie (DGHM)" and the "Unfallverhütungsvorschrift (UVV) der Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege". The different regulations and the resulting practical consequences for manual and mechanical cleaning and disinfection of rigid and flexible endoscopes are described. Particularly the HBV-HIV-problems as well as the respective inactivation times resulting there from, standby times and concentrations of different solutions for disinfection are discussed. Presentation of the practicability of the different steps in daily ENT-practice and ambulance.

[The federal communicable disease law and refuse disposal from hospitals and medical practices]

Several laws and guidelines on the disposal of waste from hospitals and practice differentiate between diverse types of waste. The LAGA instruction sheet lists five types: type A = hospital waste, type B = medical waste, type C = infectious waste, type D = chemical waste, and type E = human pathological material. Especially the basis of differentiation between medical and infectious waste is the list of notifiable infectious diseases according to section 3 of the Federal Law on Epidemic diseases. Section 10a confines the list to contagious infectious diseases. However, some tropical epidemics and endemic infectious diseases are not taken into account. On the other hand, the list includes a few harmless childhood and other diseases. There is not scientific evidence that wastes of this kind have led to infections in the community. Therefore, the Federal Law on Epidemic Diseases does not seem to be a suitable basis for the differentiation between medical and regulated medical wastes.

[Draft of the swimming pool water regulation. Presentation, status: 17 September 1991, according to the federal hearing of 11 December 1991 in Bonn]

Comments are given on the present status of regulations concerning water in swimming pools and baths--1991--(in connection with the KOK regulations--1972--and the Federal German standard [DIN] No. 19643-1984-). Reference is made to microbiologic limits of Legionella pneumophila among others.