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Waterborne Pathogensin Historical and Social

Contexts

Nursing Pathwww.drjayeshpatidar.blogspot.com

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Vibrio cholerae

one of the six waves of cholera

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John Snow

Vibrio cholerae

one of the six waves of cholera

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John Snow

Vibrio cholerae

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Fillipo Pacini

Vibrio cholerae

one of the six waves of cholera

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Robert KochNobel Prize (1905)

Vibrio cholerae

one of the six waves of cholera

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Vibrio cholerae

Rita ColwellUniversity of Marylanddiscovered O139

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Vibrio cholerae

• Symptoms– toxins lead to watery diarrhea (rice stools)– symptoms within hours

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Vibrio cholerae• Symptoms

– toxins lead to watery diarrhea (rice stools)– symptoms within hours

• Transmission– contaminated water, food (fish, shellfish), swimming– feces of asymptomatic and sick human carriers. – no person-to-person transmission

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Vibrio cholerae• Symptoms

– toxins lead to watery diarrhea (rice stools)– symptoms within hours

• Transmission– contaminated water, food (fish, shellfish), swimming– feces of asymptomatic and sick human carriers. – no person-to-person transmission

• Infectious Dose (in healthy adults)– 108-1011 cells (ID50)– antacids lower ID (= more susceptible to infection)

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Vibrio cholerae• Symptoms

– toxins lead to watery diarrhea (rice stools)– symptoms within hours

• Transmission– contaminated water, food (fish, shellfish), swimming– feces of asymptomatic and sick human carriers. – no person-to-person transmission

• Infectious Dose (in healthy adults)– 108-1011 cells (ID50)– antacids lower ID (= more susceptible to infection)

• Survival Outside Human Hosts– biofilms– zooplankton, shellfish– viable non-culturable state

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Vibrio cholerae• Detection, Monitoring Programs

– Culture: • Alkaline Peptone Water (for enrichment, 6-8 hrs @ 37oC)• Thiosulfate Citrate Bile Sucrose Agar (small yellow colonies)• Kligler Iron Agar (no gas, red slant/yellow butt)• Leucine Slants (purple slant/purple butt, no gas, no H2S)• Agglutination test for positive colonies to ID strain

– DNA-based detection• rfb (O antigen), ctxA,ctxB (cholera toxin)

• Control and Treatment– Proper water sanitation (chlorination, solar)– Rehydrate symptomatic individuals– Antibiotic (tetracycline) treatment– Vaccine (only moderately effective)– Exposure to O1 does not protect against O139

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Salmonella • WHO: 1,400,000 instances of salmonellosis in

USA• Salmonella costs per year US $3,000,000,000

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Salmonella • WHO: 1,400,000 instances of salmonellosis in USA• Salmonella costs per year US $3,000,000,000• Nomenclature evolves (old, new names co-exist...)

– the latest: S. bongori and S. enterica

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Salmonella • WHO: 1,400,000 instances of salmonellosis in USA• Salmonella costs per year US $3,000,000,000• Nomenclature evolves (old, new names co-exist...)

– the latest: S. bongori and S. enterica• 2,300 serotypes (S. enterica Typhimurium, etc)

– wide host range (humans, cattle, horses, rodents, cats, dogs, birds, reptiles)

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Salmonella • WHO: 1,400,000 instances of salmonellosis in USA• Salmonella costs per year US $3,000,000,000• Nomenclature evolves (old, new names co-exist...)

– the latest: S. bongori and S. enterica• 2,300 serotypes (S. enterica Typhimurium, etc)

– wide host range (humans, cattle, horses, rodents, cats, dogs, birds, reptiles)

• Multi-drug resistant S.e.Typhimurium DT104

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Salmonella • WHO: 1,400,000 instances of salmonellosis in USA• Salmonella costs per year US $3,000,000,000• 2,300 serotypes (S. enterica Typhimurium, etc)

– wide host range (humans, cattle, horses, rodents, cats, dogs, birds, reptiles)

• Multi-drug resistant S.e.Typhimurium DT104• Most common diseases caused by Salmonella:

– gastroenteritis (self-limiting, 2-5 days)– enteric/typhoid fever (incubation 1-10/7-14 days, lasts 2-3

wks)– septicemia (incubation12-36 hrs, may lead to chronic infection)– symptoms and disease manifestation differ in hosts

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Daniel Elmer Salmón (1850-1914)

Salmonella enterica

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Mary Mallon

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Mary Mallon

237 other “healthy” carriers in NY at the same time(none of the 237 were ostracized like Mary Mallon)

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Salmonella

Most “commonly-used” bioterrorism agent

1939. Japanese Imperial Army contaminated rivers on the Manchurian border

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Salmonella

Most “commonly-used” bioterrorism agent

1939. Japanese Imperial Army contaminated rivers on the Manchurian border

1972. “Order of the Rising Sun” obtains S. Typhi to contaminate water supplies in Midwest

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Salmonella

Most “commonly-used” bioterrorism agent

1939. Japanese Imperial Army contaminated rivers on the Manchurian border

1972. “Order of the Rising Sun” obtains S. Typhi to contaminate water supplies in Midwest

1984. Rajneesh Cult. Successfully contaminates restaurants in Dalles, OR in an attempt to thwart local elections

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Salmonella

• Transmission– Human-to-human (S. Typhi)– Pets (often asymptomatic carriers)

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Salmonella

• Transmission– Human-to-human (S. Typhi)– Pets (often asymptomatic carriers)– Contaminated foods, milk, drinking water

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Salmonella

• Transmission– Human-to-human (S. Typhi)– Pets (often asymptomatic carriers)– Contaminated foods, milk, drinking water– Eggs and poultry (S. Enteriditis)

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Salmonella

• Transmission– Human-to-human (S. Typhi)– Pets (often asymptomatic carriers)– Contaminated foods, milk, drinking water– Eggs and poultry (S. Enteriditis)

• Infectious Dose (in healthy adults)– 20-100 cells …. 1 mln cells

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Salmonella

• Transmission– Human-to-human (S. Typhi)– Pets (often asymptomatic carriers)– Contaminated foods, milk, drinking water– Eggs and poultry (S. Enteriditis)

• Infectious Dose (in healthy adults)– 20-100 cells …. 1 mln cells – mice become infected only after normal gut flora is killed!

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Escherichia coli

Theodor Escherich(1857-1911)

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Escherichia coli

Lee W. RileyUniversity of Berkeley

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Escherichia coli• Normal flora of human GI• Uropathogenic E. coli. 90% of all UTI• Enterovirulent E. coli serotypes

– Enteroinvasive E. coli (EIEC). – Enterohemorrhagic E. coli (EHEC=VTEC) O157:H7.

Bloody diarrhea. Hemolytic Uremic Syndrome (HUS). – Enterotoxigenic E. coli (ETEC). Travelers diarrhea (cholera-

like).– Enteropathogenic E. coli (EPEC). Diarrhea in newborn

nurseries.– Enteroaggregative E. coli (EAggEC). Acute and chronic

diarrhea in children

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Annual Cost of Pathogenic E. coli

O157:H7 cases

Non O157:H7 STEC cases

O157:H7 costs Non O157:H7 costs

No medical care 35, 632 17, 816 N/A N/A

Physician visit 24, 983 12, 492 $ 6, 900, 000 $ 3, 400, 000

Hospitalized, survived 1790 895 $ 32, 900, 000 $ 16, 500, 000

Deaths 52 26 $ 1, 500, 000 $800, 000

Chronic illness, HUS 46 23 $ 36, 500, 000 $18, 500, 000

Total 60, 615 30, 308 $659, 000, 000 (includes lost productivity)

$ 329, 700, 000(includes lost productivity)

Source: Economic Research Service, USDA, Oct. 20, 2000.

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Legionella pneumophila

Bellevue-Stratford Hotel, Philadelphia

10,000-20,000 estimated cases per year

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Legionella pneumophila• Symptoms

– appear within 2-10 days after exposure– Legionnaire’s disease: pneumonia. Also affects nervous, GI, urinary systems.

Highly fatal.– Pontiac fever: flu-like, self-limiting, mild non-pneumonic

• Transmission– no known human-to-human transmission– inhaling or injecting droplets with bacterial cells

• Survival Outside Human Hosts– aquatic biofilms

• naturally in hot springs, rivers, etc• cooling towers, any warm water reservoirs• hot tubs, AC units (mostly industrial)

– amoebae (symbiont or pathogen)– Cyanobacteria– Legionella longbeachea. Potting soil

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Legionella pneumophila• Detection, Monitoring Programs

– Culture: Buffered Charcoal Yeast Extract Agar + L-cysteine + Fe.

• 5 days @ 37oC• cannot use carbohydrates

– PCR. Commercial kits available– Serological methods (most common)

• monoclonal antibodies seem more specific• no single antiserum is used routinely to ID all Legionella• Direct fluorescent antibody staining

– rapid (2-4 hrs)– specific. Rarely cross react with Pseudomonas.– sensitivity improved by sample quality, # bacteria

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Legionella pneumophila• Control and Prevention

– Legionella are ubiquitous. Monitoring is nearly impossible– copper-silver ionization for hot water– super heat/flush cycles (>50-60 oC for >30 min)– UV – Hyperchlorination (1-2 ppm residual)– Monochloramine seems to be more effective than chlorine

• more stable?• penetrates biofilms?

– personal protection while servicing exposed equipment– stop smoking!

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Thank You