Ashbolt Circumpolar Water Health - Universitetet i Tromsø ... risk assessment.pdf · Yesinia enterocolita – Grave’s Disease –!Giardia lamblia - hypothyroidism –!Helicobacter

Waterborne and Water-‐Based Microbial Pathogens: Ar7c Community Water Sanita7on August 4, 2015

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Waterborne and Water-Based Microbial Pathogens: Artic

Community Water and Sanitation Nicholas Ashbolt, Alberta Innovates Health

Solutions Translational Health Chair in Water

[email protected]

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

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Death rate from typhoid/cholera USA 1900-1960

Surface/ Ground water

•  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

Traditional domestic water services

Challenges

Household Water treatment

SepCc tank / leachfield

Pathogens Nutrients Drugs Biocides

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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!O<PH5/<!Q3<3$4!+,*(!K''R,'!)S/%&!B45!-/#%4!H<!5#530!"03%D3!&/!B5/PH=4!BHB4=!>3&45:%4>3$4!!KS#AAH<$!!"#$%&#L)*+'M!FT/8!U<4!!V!L+)M(!4++'WVV!

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Cleaning vs. Hygiene •! Meta-analysis of impact of cleaning and disease

reduction indicates normal household cleaning may increase illness rates (Paul Hunter)

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Some facts about environmentally transmitted illness

•  80% of all infectious diseases environmentally transmitted

•  You will experience viral illness 10% of your lifetime •  In the United States you will have a foodborne

illness at least every 5 to 6 years (~46 million / y) •  Most colds and flu are transmitted by fomites •  Children experience 3-6 respiratory infection per

year. Adults 1 to 3 per year (Chuck Gerba pers. Comm.)

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Generally can not solely rely on outbreak data to estimate risks

Num

ber

of C

ases

Time

Threshold for detection for an outbreak

Endemic rate

Outbreak detected

Undetected outbreak

Hyperendemic

Sporadic

Frost et al. (1996) J AWWA 88(9): 66-75

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[Total:reported case 10 to 500:1]


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French NaConal Health Insurance InformaCon System (SNIIRAM)

French cohort DW outbreak vs AGI drug use Mouly et al. 2015 Epi Inf 10.1017/S0950268815001673

A`ach rate from drinking water with > 100 E. coli / 100 mL 1-‐10% Campylobacter sp. via mountain spring (1067 people, 39·∙6% studied)

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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)

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Importance of minor human impact •! Most epidemiology

studies for rec water lacked statistical power, nor were they designed to specifically investigate health relationships to fecal indicators as well as bather density or other faecal source mixes

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Disease agents from 780 drinking water outbreaks, 1971-2006 USA water outbreaks, 1971-2006 USA

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(403,000 cases from a single outbreak of Cryptosporidium hominis in Milwaukee (WI) April 1993, but only 9% of outbreaks vs. Giardia 86%)

Unknown, 45% (85% Norovirus)

(30% Cu, 12% F, 9% NO3

- )

Craun et al. (2010) Clin Microbiol Rev 23: 507-528

(28% since 2001)

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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

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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

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Various pathogen sequelae •! Carcinogens

–!Helicobacter pylori, cyanotoxins •! Teratogens

–!Toxoplasma gondii –!Coxsackievirus

•! Renal disease –!E. coli O157:H7, Microsporidium spp.

•! Hepatogens –!Hepatitis A & E viruses, cyanotoxins

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Various pathogen sequelae

cyanotoxins

Microsporidium spp.

cyanotoxins

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)


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WHO’s new focus: global AMR

*Ashbolt et al. (2013) Env Health Perspect 121(9), 993-‐1001 **Hoffman et al. (2015) Bull WHO 3(2), 66

•  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*

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Kennedy (2014) NYTimes 8 March

•  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

Antibiotic-resistant bacteria via drinking water?

Cox & Blaser (2013) Cell Metab 17: 883-‐94 Gough et al. (2014) BMJ 348: g2267

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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-log10 (99.99%) reduction of enteric viruses and 3-log10 (99.9%) for

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-log10

(virus, parasite, bacteria), i.e. generally better than required

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*ArcCc Monitoring and Assessment Programme (Donaldson et al. 2010 SOTE 408: 5165-‐234)

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

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•  WHO & EPA set water criteria and/or treatment requirements based on QMRA (& epidemiology) studies

•  Risk-based performance targets. e.g. EPA surface waters –  4 log virus & 3 log parasite removal for drinking waters (DW)

•  Example risk-based targets for QMRA –  Not current EPA policy, Dutch reg: DW < 10-4 infection / y –  WHO/AUS/CAN: DW & reuse: < 10-6 DALY/year –  EPA policy: swimming < 30 gastro/1000 people.day

Quantitative Microbial Risk Assessment (QMRA): Regulatory & operational uses

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Medema, Loret, Stenström & Ashbolt 2006 Quan:ta:ve Microbial Risk Assessment in the Water Safety Plan. Final Report on the EU MicroRisk Project. European Commission: Brussels; www.microrisk.com/publish/cat_index_11.shtml Soller et al. 2015 EsCmated human health risks from recreaConal exposures to stormwater runoff containing animal fecal material. Environ Modelling SoJware 72: 21-‐32

Example performance targets (Australian, water reuse)

Activity Exposure Log10 reduction required (L / year) Crypto Rotavirus Campylobacter

Residential use 0.66 4.9 6.0 5.0 Commercial crops 0.49 4.8 5.9 4.9 Urban irrigation 0.05 3.7 4.8 3.8

Performance target = reducCon in hazard for < 10-‐6 DALY/y (based on a QMRA analysis)

ResidenCal use = outdoor use, toilet flushing & clothes washing Commercial crops include spray irrigaCon of salad vegetables

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Enteric/Zoonotic & Saprozoic pathogens

Viruses Bacteria Parasitic protozoa

Legionella in human lung macrophages

Free-living protozoa – natural host to environ pathogens

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Quantitative microbial

risk assessment

(QMRA)

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B3&-/$4<%!3<=!H=4<CE73C/<!/9!-3p35=/#%!4P4<&%)STEP 1 SETTING

Dose-Response (Pinf ) Selection of appropriate models for each

ref pathogen and groups exposed

STEP 3 HEALTH EFFECTS

Source water Ref pathogen densities

Treatment Surrogate removals

Environ Pathogen growth in pipes & Ingress of faecal

pathogens Human exposures

Vol water intake

microbial STEP 2 EXPOSURE

(Penv-path) Distribution

Pathogen loss (biofilm/death)

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STEP 4 RISK

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WHO Risk management framework

Fewtrell & Bartram (2001) Water Quality: Guidelines, Standards and Health. Risk Assessment and Management for Water Related Infectious Diseases, WHO, Geneva

HEALTH TARGETS

PUBLIC HEALTH STATUS

Risk Management

Risk Risk Assessment

Assess exposures

Tolerable Risk

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System verification: 100 years experience with faecal

indicator bacteria, but!

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indicator bacteria, but

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Microbial monitoring can not show drinking water is safe 95% of the time Nominal log10 reduction #/year Monitoring interval

0.05 1 1 year 1 30 1 week 2 300 1 day 3 3,000 3 hours

4 (99.99%) 30,000 15 min 5 300,000 2 min 6 3,000,000 10 sec 7 30,000,000 1 sec

For 100,000 m3/day water treatment plant designed for 4-log virus kill

Smeets et al. (2010) Water Sci Technol 61: 1561-8

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US Domestic water use*

Water system issues: access-population growth, climate change, & eco-service loss

•! Need adaptive approaches to aid decision-making, and: –! Treating water so fit-for-purpose

•! ~20% needed at drinking water quality

–! With full cost accounting for water services driven by resource recovery (energy, heat, water!) for the built environment system life-time

*American Water Works Association

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Possible drivers for infrastructure change 1.! Insurance industry drove waterworks for fire-fighting, via

reduced home premiums (since 1872 in N. America) 2.! Disease but ignorance of 30% outbreaks & 80% health

burden not faecal in origin, >$790 M/y in the USA* 3.! Financial-political sustainability, e.g.

–! $20 billion/y annual short-fall in US water system maintenance (EPA GAP report, 2005) no political will

*Collier et al. (2012) Epi Inf 140(11): 2003-13

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Drivers/outcomes – need political will for: •! Reduce energy use + GHG & nutrient emissions

•! Market-driven water, energy & nutrient recovery •! Climate- & demographic-resilient infrastructure

•! Decentralized, adaptable and antifragile*

Alternative community water elements for ‘One-water’ concept, market led

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*Nassim (2012) Antifragile: Things That Gain from

Disorder, Random House

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What are the pathogen issues with these alternative systems? •  Reclaimed sewage for non-/potable use

– Norovirus, Rotavirus, Cryptosporidium •  Reclaimed greywater for toilet flushing

clothes washing & garden/crop irrigation – Skin (Staph. aureus) & aerosol (Legionella, NTM)

as well as enteric pathogens via raw veggies •  Recovered nutrients for plant fertilizer

– Antimicrobial resistant genes/pathogens

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Example targets for greywater reuse •  Accidental ingestion of reclaimed greywater assumed

< 40 mL/day.person; as used by U.S. EPA recreational water criteria (2012); acceptable risk 7 illness/1000 swims

•  Household washing water to meet –  9-log10 virus, 8-log10 protozoa/bacteria reduction, being

safer than recreational waters, and << home-exposure (person-to-person) pathogens in aboriginal communities

–  Validation needed by virus/parasite/bacteria surrogates •  Strictest requirements, California Title 22 (2014) for Indirect

Potable Reuse of municipal wastewater: –  12-log10 virus, 10-log10 protozoa/bacteria reduction –  Which assumes > 1-L consumed/day.person

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Example household greywater log-reductions by system elements

Element Viruses Bacteria Protozoa Comment Biofilter 1 1 1 Short-circuiting ? Requires

unsaturated flow

MF/UF 2/5 4 4 Caking may increase removal

UV 4 4 4 Need signal light working

Total 7/10 9 9 Some leeway for poorer performance

Target 9 8 8

§  Pilot testing as per Title 22 (2014) challenge spiking with MS2 bacteriophage (virus surrogate), E. coli (bacteria), and Clostridium perfringens spores (protozoan surrogates for removal/inactivation) – max 6-log10 credit per element

§  Baffles in the biofilter zone need to be explored to increase the recirculating ratio and impact on log reductions, BOD removal

33

Example toilet & greywater options

Graywater treatment

Urine-diversion toilet

Vacuum toilet

Foam-flush composting-toilet

34

Loowatt-toilet (http://loowatt.com)



35

Blackwater energy-nutrient recovery Sneek, the Netherlands 2015

35

QMRA within broader sustainability assessments

36

Ashbolt et al. (2006) In: 2nd IWA Leading-‐Edge on Sustainability in Water-‐Limited Environments. WEMS vol 10, IWA Publishing, London Kobayashi et al. (2015) Water Res 2015, 79, 26-‐38; Xue et al. (2015) Water Res 77: 155-‐169

Irrigation

Fertilizer (NPK)

www.urbanwater.org

Water fit-‐for-‐purpose Resource-‐recovery systems

Reuse

Combined Heat & Power

Fertilizer (NPK)

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Cape Cod MA - Case Study

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Cape Cod MA - Case Study

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Xue et al. Water Res, accepted

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Cape Cod alternative costs •! Nitrogen management seen as the critical

problem, and –!Least life-cycle costs ($1,900/y) & $300/kg N

removed from the watershed with urine-diversion composting toilets paired with greywater reuse

–!Centralised wastewater treatment was the most expensive ($3,500/y) & least cost-effective option $600/kg N removed

Wood et al. (2015) J Environ Manage 150: 344-54

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LCA Energy consumption

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Life Cycle Assessment (LCA)

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Life Cycle Assessment (LCA)

LCA Global warming potential

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Human Health Risk Assessment •! 5 Reference pathogens used in the QMRA

–! Dose estimates for household & recreational exposure routes

•! 2 Disinfection by-products (DBPs) –! The highest-risk class of chemicals associated with

water & urban living (bladder cancer) –! Focus on chloroform & bromodichloromethane

•! Most risk from recreational water; e.g. as % of BAU

–! 63% for urine-diversion/septic, 23% composting toilet/septic, 15% for blackwater sewer, greywater reuse + RWH vs 1% without rainwater use

Schoen et al. (2014) Environ Sci Technol 48: 9728-36

')!

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Circumpolar water-related health •  Community diseases result from:

–  Inadequate water and sanitation •  waterborne & water-based pathogens

– Lack of body and clothes washing •  skin infections

– Respiratory infections •  person-to-person in group settings + water-based •  such as reduced with Kivalina washeteria closures 1

•  Solutions must address aboriginal societal needs 2

43

1Thomas et al. (2013) Int J Circumpolar Health 72(Suppl 1): 480-‐483 2Daley et al. (2015) Social Sci & Med 135: 124-‐132

Wales

Tuntutuliak x

x

Community situations differ: e.g. Wales and Tuntutuliak, Alaska

44

Circumpolar populaCon ~ 4 m, 10% indigenous ancestry (Dudley et al. 2015 EcoHealth)

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Water needs for health

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"!Social research conducted in Wales and Tuntutuliak identified residents only used between 1 and 3 gallons per capita per day for all current household uses (drinking, cooking, washing)

"! i.e., significantly below that recommended by Institute of Medicine / WHO

"!Suggest that out of 10 gpd potable water for a household of four, 2.8 gallons for drinking, 4.2 gallons for washing, 3.0 gallons food preparation

Geography defines possible water sources, which influences Arctic system designs

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Wales Tuntutuliak

Preferences and social practices determine how water is used e.g. washing people

?B)

Current preferences are influenced by many factors: historical events, economics, habits...

?C)

Wales Tuntutuliak

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Wales Tuntutuliak

Community capital and local economic viability determine what

services are possible long term

?D)

@F)

Available infrastructure impacts health risks: haulage in and out

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Available infrastructure impacts health risks: local drinking water storages increase risk

@E)

Arctic sea ice cover 1984 vs 2012

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@=)



h`p://nca2014.globalchange.gov/report/sectors/indigenous-‐peoples#tab2-‐images

Loss of Permafrost (1 m depth)

53

Loss of Permafrost •  Resulting in serious erosion, flooding, and

destruction of homes, buildings, and roads from differential settlement, slumping, and/or collapse of underlying base sediments

•  Loss of clean water for drinking and hygiene, saltwater intrusion, and sewage contamination that could cause respiratory, gastrointestinal and skin infections

54



Circumpolar-relevant water pathogens •  Enteric waterborne (human & zoonotic) diseases

–  Hepatitis A, Norovirus gastro, Shigella spp. bacterial dysentery –  Giardia giardiasis, enteritis Yersinia & Campylobacter spp. –  Echinococcus multilocularis (lung disease) via foxes/voles

•  Water-based (saprozoic) diseases –  Non-tuberculous mycobacteria (wound/lung), Helico. pylori? –  V. parahemolyticus/vulnificus gastro as seawater > 15 C

•  Person-to-person spread of: –  Norovirus, Cryptosporidium hominis & various helminths –  TB, Strep. pneumoniae, Haemophilus influenzae along with

multi-drug resistant strains Parkinson & Evengård (2009) Glob Health Ac:on 2: 1-‐3 Dudarev et al. (2013) Int J Circumpolar Health 72, (1): 1-‐10

55

Example control of pathogens via one-health approach

•  Antimicrobial treatment for Helicobacter pylori infection: 58% pop positive to < 9% (Aklavik NWT study) 1

•  Containment of sewage/stormwater runoff to native mammals: for Toxoplasma gondii, Giardia, Echinococcus

•  Mosquito control – e.g. West Nile, Hare & influenza viruses

1Carraher et al. (2013) Int J Circumpolar Health 72:21594 Cheung et al. (2014) BMJ Open 4:e003689

One Health approach include interacCons between and among humans, animals, plants, parasites, microbes, and chemical contaminants in terrestrial, aquaCc, & marine ecosystems

56



However not necessarily good to treat all H. pylori cases

•  A group of international experts performed a targeted literature review and formulated an expert opinion for evidenced-based benefits and harms for screening and treatment of H. pylori in high-prevalence countries –  In Arctic countries where H. pylori prevalence exceeds 60%,

treating H. pylori infection should be limited to peptic ulcer disease and mucosa-associated lymphoid tissue lymphoma and

–  That the test-and-treat strategy may not be beneficial for those with dyspepsia

McMahon et al. (2015) Epi Inf DOI: 10.1017/S0950268815001181

57

One-health potential climate impacts

58

Dudley et al. (2015) EcoHealth 10.1007/s10393-‐015-‐1036-‐1

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Key take home points •! Traditional community water systems

not possible due to water scarcity & ecosystem impacts and generally not economic anywhere (longer-term) –! Need a systems view to identify alternatives –! Including energy, heat, fertilizers + water

fit-for-purpose, with community-led selection –! Water-based pathogens now most important

to manage (+antibiotic-resistant ones), yet currently unregulated!

@D)

Take home point – 2 (not DBP but NTM!)

•! Once you manage enteric pathogens water-based pathogens likely to cause most health burden, via respiratory & wound infections –!Non-tuberculous mycobacterial (NTM) infections

now > TB in NA & EU, & infection only via water

–!Similarly Legionella pneumophila only via aerosols and mostly grow in biofilm amoebae

W*!



Questions?

•  Helen Buse (Lau), Mary Schoen, Jingrang Lu, Randy Revetta, Jorge Santo Domingo & Vicente Gomez-Alvarez, Xiaobo Xue, Troy Hawkins & Jay Garland U.S. Environmental Protection Agency Cincinnati OH

•  David Roser, Jacquie Thomas & Michael Storey University of New South Wales-Sydney

•  Norm Neumann, Zhi Shuai, Graham Banting, Qiaozhi Li, Md. Shaheen, Shannon Braithwaite School of Public Health, University of Alberta

Acknowledgments

61

Documents

Ashbolt Circumpolar Water Health - Universitetet i Tromsø ... risk assessment.pdf · Yesinia enterocolita – Grave’s Disease –!Giardia lamblia - hypothyroidism –!Helicobacter