Waterborne and Water-‐Based Microbial Pathogens: Ar7c Community Water Sanita7on August 4, 2015 Ashbolt@Ualberta.ca Waterborne and Water-Based Microbial Pathogens: Artic Community Water and Sanitation Nicholas Ashbolt, Alberta Innovates Health Solutions Translational Health Chair in Water Waterborne disease history •  1854 – John Snow links cholera & water in UK •  1854 / 1884 cholera bacteria isolated/described •  1900 – Filtration of water supplies begins in the North America – major drop in typhoid & cholera observed in cities using filtration •  1909 – Chlorination of water supplies begins in the United States – further drop •  1993 – Largest waterborne outbreak every documented in the United States ~ 400,000 ill and 97 die – Cryptosporidium hominis •  2009 –Largest swimming outbreak in history ~4,000 ill – Cryptosporidium hominis 2 Ashbolt@Ualberta.ca 1 Waterborne and Water-‐Based Microbial Pathogens: Ar7c Community Water Sanita7on August 4, 2015 Death rate from typhoid/cholera USA 1900-1960 3 Traditional domestic water services Surface/ Ground Water Household water treatment Pathogens Nutrients SepCc tank / Drugs Challenges leachﬁeld Biocides •  Water services use 3-7% of a nation’s electricity (yield 3% GHG) • vs 14% for hot water (household heating 29% & cooling 17%) •  Aging water and wastewater infrastructure $billions to maintain •  Sewer/septic system releases – major cause of eutrophication •  Neither climate/demographic resilient nor economic 4 Ashbolt@Ualberta.ca 2 !"#$%&'%($)"(*)!"#$%+,"-$*)./0%'&/"1)2"#3'4$(-5)6%70)8'99:(/#;)!"#$%))<"(/#"7'(! "#$#%&!!'(!)*+,! Nature of the WASH problem • Developed countries: treated DW, flush toilet- ! sewerage; yet most expensive option1 ($160k/h2) • 32-36% of global pop lack household-level ! access to safe water or hygienic toilets3 • 1.5 B people in developing regions use ! sanitation systems that do not protect others3 • Hence, promotion of urine-diverting toilets, ! blackwater to biogas, dry composting toilets! +@//=!!"#$%&!L)*+,M!N!O3&45:%4>3$4!! KS#AAH<$!!"#$%&#L)*+'M!FT/8!U<4!!V!L+)M(!4++'WVV! @) Cleaning vs. Hygiene • Meta-analysis of impact of cleaning and disease ! reduction indicates normal household cleaning may increase illness rates (Paul Hunter) S043 100 E. coli / 100 mL 1-‐10% Campylobacter sp. via mountain spring (1067 people, 39·∙6% studied) 9 How much illness via US tap water? •  Municipal drinking water cases of diarrhea – 12 million cases/y (Colford et al. 2006) – 16 million cases/y (Messner et al. 2006) – 19.5 million in municipal & individual systems (Reynolds et al. 2007) – 24 million waterborne+water-based (Gerba, 2012) •  5,000 deaths/y CDC (waterborne organisms) •  7,000 to 20,000 deaths/y by water-based pathogens (CDC, 2012) 10 Ashbolt@Ualberta.ca 5 !"#$%&'%($)"(*)!"#$%+,"-$*)./0%'&/"1)2"#3'4$(-5)6%70)8'99:(/#;)!"#$%))<"(/#"7'(! "#$#%&!!'(!)*+,! Importance of minor human impact • Most epidemiology G=FH)3:9"()$(#$%'0'00/)9";&$)-/45) ! I28J).3$4! investigate health ;^!^00 relationships to .6! / _H%D!95/A!$#00%! fecal indicators as F5!!!! 3%%#AH<$!)*b!-#A3:?/1,@.&'5A*' (30% Cu, 12% F, 9% NO - ) 3 7$"8!"#$%&"''(' 9,13:-/,;'5<*' Craun et al. (2010) Clin Microbiol Rev +,-,./01' (403,000 cases from a single outbreak of 23: 507-528 2-$3$4$,&'56*' Cryptosporidium hominis in Milwaukee (WI) Apri l 1993, but only 9% of outbreaks vs. Giardia 86%) E=) "%-./0&1230.45&3673! W! Waterborne and Water-‐Based Microbial Pathogens: Ar7c Community Water Sanita7on August 4, 2015 Public health hospitalization costs associated with US drinking water* •  CDC estimate drinking water disease costs > $970 m/y – Less so faecal pathogens, largely Legionnaires’ disease, otitis externa, and non-tuberculous mycobacterial (NTM) giving >40 000 hospitalizations/y Disease Annual costs Cryptosporidiosis $46M Giardiasis $34M Legionnaires’ disease $434M NTM infection/Pulmonary $426M/ $195M *Collier et al. (2012) Epi Inf 140(11): 2003-13 13 Sequelae •  Disease that develops only after initial infection has occurred •  This can occur days, weeks or years after initial infection •  Examples: auto-immune disease Ø  Diabetes Ø  Heart disease Ø  Liver damage Ø  Reactive arthritis 14 Ashbolt@Ualberta.ca 7 !"#$%&'%($)"(*)!"#$%+,"-$*)./0%'&/"1)2"#3'4$(-5)6%70)8'99:(/#;)!"#$%))<"(/#"7'(! "#$#%&!!'(!)*+,! VVaarriioouuss ppaatthhooggeenn sseeqquueellaaee • Carcinogens ! – Helicobacter pylori, ccyyaannoottooxxiinnss ! • Teratogens ! – Toxoplasma gondii ! – Coxsackievirus ! • Renal disease ! – E. coli O157:H7, MMiiccrroossppoorriiddiiuumm sspppp.. ! • Hepatogens ! – Hepatitis A & E viruses, ccyyaannoottooxxiinnss ! E@) Various pathogen sequelae • Nervous system disorders ! – Campylobacter jejuni, various Enterovirus spp. ! • Heart disease ! – Adenovirus, Coxsackievirus ! • Endocrine disrupters ! – Coxsackievirus – Orchitis ! – Yesinia enterocolita – Grave’s Disease ! – Giardia lamblia - hypothyroidism ! – Helicobacter pylori - atrophic thyroiditis ? ! EA) "%-./0&1230.45&3673! f! Waterborne and Water-‐Based Microbial Pathogens: Ar7c Community Water Sanita7on August 4, 2015 WHO’s new focus: global AMR •  3rd gen cephalosporin-resistant E. coli & MRSA predicted deaths 3.3 per 100,000 in EU in 2015* •  Globally 700,000 AMR-deaths, some 10 million by 2050** •  Unclear fraction due to water* *Ashbolt et al. (2013) Env Health Perspect 121(9), 993-‐1001 **Hoﬀman et al. (2015) Bull WHO 3(2), 66 17 Antibiotic-resistant bacteria via drinking water? •  Fat Drugs (antibiotics promote child weight) –  Used in agriculture for weight gain –  Part of the human obesity problem •  Primary waterborne sources include –  Wastewater (industry & hospitals) –  Animal production/manures •  Mass delivery via water? –  Water disinfectants and metal pipes known to increase gene exchange within biofilms loss of AB efficacy Cox & Blaser (2013) Cell Metab 17: 883-‐94 Gough et al. (2014) BMJ 348: g2267 Kennedy (2014) NYTimes 8 March 18 Ashbolt@Ualberta.ca 9 Waterborne and Water-‐Based Microbial Pathogens: Ar7c Community Water Sanita7on August 4, 2015 Health hazards in drinking waters •  Pathogens generally a significantly greater risk than chemicals via water/sanitation (despite chem focus*) •  Helminths largely impact via direct faecal contact •  U.S. EPA Safe Drinking Water Act & Health Canada require (based on quantitative microbial risk assessment QMRA): –  4-log (99.99%) reduction of enteric viruses and 3-log (99.9%) for 10 10 parasitic protozoa; and verification with no E. coli per 100 mL from surface water supplies (monitoring if supplied to > 25 people) –  To give: annual risks < 1 infection / 10,000/y or < 1 microDALY/y Ø Proposed Arctic household D water: MF/UF + UV > 4-log 10 (virus, parasite, bacteria), i.e. generally better than required *ArcCc Monitoring and Assessment Programme (Donaldson et al. 2010 SOTE 408: 5165-‐234) 19 Acceptable or tolerable risk •  Haas (1996) describes 1980’s EPA Surface Water Treatment Rule, 10-4 per y: – current practices (late 1980’s) considered to be producing water of acceptable level of risk – reported outbreak caseloads approximated one illness per 10,000 per annum – infection rather than illness, since many illnesses go unreported & so covers the more susceptible – lifetime risk of death due to waterborne infections at a 1:10,000 level estimated 10-6-10-5 range, which was in line with chemical risk assessment 20 Ashbolt@Ualberta.ca 10

Nick Ashbolt - Waterborne and Water-Based Microbial Pathogens

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