UMass Amherst - Waterborne Disease Risk...Water-Related Diseases (~80% infectious diseases)...
Transcript of UMass Amherst - Waterborne Disease Risk...Water-Related Diseases (~80% infectious diseases)...
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Waterborne Disease Risk
http://extension.usu.edu/agwastemanagement/Permits/cafo-permit
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Outline
1. The Global Problem
2. The epidemiological link
3. The US
4. Assessing risk
5. Small water systems – the Walkerton experience
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Water-Related Diseases (~80% infectious diseases)
Waterborne:
Cholera, typhoid, bacillary dysentery, infectious hepatitis
Water-washed:
Trachoma, scabia, dysentery, louse-borne fever
Water-based:
Schistosomiasis, Guinea worm
Water-related (insect vector):
Malaria, sleeping sickness, onchocerciasis
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Leading causes of mortality from infectious
diseases (WHO 2015 and 2016 estimates)
Disease Mortality
LRI 3.2 million
Diarrheal Diseases 1.4 million
Tuberculosis 1.4 million
HIV/AIDS 1.1 million
Malaria 0.4 million
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Percentage of deaths among children under age 5 attributable to diarrhoea, 2015. https://data.unicef.org/topic/child-health/diarrhoeal-disease/
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• 842,000 people die every year from diarrhoeal diseases linked to inadequate water, sanitation and hygiene
• 748 million people lacked access to improved water sources (11% of the global population)
• 2.5 billion people lacked access to improved sanitation (36% of the world’s population)
• 1 billion practice open defecation
(Prüss-Üstün et al. 2014. Trop. Med. Int. Health 19:894-905)
The Size of the Problem in 2012
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The good news in 2012:
• Mortality estimates related to WASH much lower than a
decade ago
• Since 1990,
• >2 billion gained access to improved water sources
(now 89% global population with 116 countries
meeting MDG)
• Almost 2 billion gained access to improved
sanitation (now 64%, with 77 countries meeting
MDG)
The focus today is on the extreme disparities, with poor,
marginalized (and often rural) peoples bearing the burden
of disease
(Progress on Drinking Water and Sanitation 2014 update, UNICEF & WHO)
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How do you make the
epidemiological link between
human disease and water, in order
to inform policy decisions?
officially reported data vs. self reported data
(questionnaire-based studies)
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Individual
Infection
Diarrheal illness
Moderate-severe
Physician visit
Clinical testing
Pathogen diagnosed
Disease reported
[“community” incidence]
[“hospital” incidence]
Exposure (consumption of water; # pathogens)
(pathogen infectivity, host susceptibility)
pD
pV
pM
pT
pP
pR
pI
pE
Hospital incidence =
pE x pI x pD x pM x
pV x pT x pP x pR
adapted from Pertz et al. 1998. Am J Epid 147:289-301
The problem of underreporting
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Physician
visits
Other
Source
water
Drinking
water POU
Individual
or familyDiarrhea,
vomiting
Specific
diagnoses
Treated
water
Other risk factors and
exposure pathways
Questionnaire
based study
Adapted from R. Morris, 2000
Officially reported
data
Exposure
pathways
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Water Quality and Health Studies in Hyderabad, India
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
0
10
20
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50
60
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90
100
Waterborne diseases in Hyderabad by Zone(Jatish Mohanty, HSPH doctoral thesis, 1996)
TotalAGI
TyphoidHep A
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Risk Factors for Disease
•Sewage around home •Lack of education•Deteriorating infrastructure
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Cleaning utensils on the roadUse of damaged foodDrinking water w/o residual chlorineUsing mud as a cleaning agent
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How about the US?
Relatively protected sources are susceptible to contamination from wildlife, accidents or contaminated groundwater flows
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Surface Waters? e.g., the
Ohio River
“out of 58 water supply intakes along ~980 miles of river, 48 are within 5 miles downstream of effluent discharge from a wastewater treatment plant
a study of 20 cities serving 7 million people estimated minimum wastewater component ranged from 2.3-18% and increased to predominantly wastewater for several municipalities during low flow periods”
McFeters
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Cryptosporidium parvumhttp://www.biosci.ohio-state.edu/~parasite/protozoans.html
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Change in complacency with Milwaukee Cryptosporidiosis outbreak
estimates of >400,000 sick
>100 related deaths
probably related to poor filter backflushing practices at one of Milwaukee’s treatment plants
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Microbiological Risk Assessment (MRA)
(1). Hazard identification
can we measure pathogens? are they viable? are they infectious?
what about pathogen/pathogen and pathogen/chemical mixtures?
(2). Exposure assessment
for most infectious agents; waterborne (drinking? showering? toilet
flushing, etc?), foodborne, fecal-oral?
(3). Dose-response analysis
most susceptible individual? mixtures?
(4). Risk characterization
numbers and severity
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Pathogens in drinking water (infectious dose, incidence and survival)
Infectious Estimated SurvivalDose Incidence (US) DW (d)
Bacteria Vibrio cholerae 108 (v. few) 30Salmonella spp. 106-7 59,000 60-90Shigella spp. 102 35,000 30toxigenic E. coli 102-9 150,000 90Campylobacter spp. 106 320,000 7Leptospira spp. 3 ? ?Francisella tularensis 10 ? ?Yersinia enterocolitica 109 ? 90Aeromonas spp. 108 ? 90Helicobacter pylori ? high ?Legionella pneumophila >10 11,000 longMycobacterium avium ? ? long
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Infectious Estimated SurvivalDose Incidence (US) DW (d)
ProtozoaGiardia lambia 1-10 260,000 25Cryprosporidium parvum 1-30 420,000 ?Naegleria fowleri ? ? ?Acanthamoeba spp. ? ? ?Entamoeba histolica 10-100 ? 25Cyclospora cayetanensis ? ? ?Isospora belli ? ? ?The Microsporidia ? ? ?Ballantidium coli 25-100 ? 20Toxoplasma gondii ? ? ? Viruses*
Total estimates: 1-10 6,500,000 5-27
*Includes Norwalk virus, Rotavirus, Coxsachievirus, Echovirus, Reovirus, Adenovirus, HAV, HEV, Poliovirus, SRSV, Astrovirus, Coronavirus, Calicivirus, and unkown viruses
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EPA’s Contaminant ListCCL-4AdenovirusCalicivirusEnterovirusHepatitis A virusCampylobacter jejuniEscherichia coli (0157)Helicobacter pyloriLegionella pneumophilaMycobacterium aviumNaegleria fowleriSalmonella enterica
RegulatedCryptosporidiumGiardiaHeterotrophic plate countLegionellaTotal coliforms, including fecal coliform and E. coliTurbidityViruses (enteric)(DBPs)
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Microbiological Risk Assessment “to predict how many people in the community are infected through
drinking water consumption under non-outbreak conditions
to determine pathogen densities which give an acceptable risk and hence to set microbiological standards for drinking water supplies
to determine the effectiveness of drinking water treatment for different source waters and to estimate the increased risk if a drinking water treatment fails
to balance microbial risks against the chemical risks from disinfection by-products and to assess the microbiological impact of eliminating disinfection on public health
to identify the most cost effective option to reduce microbiological health risks to drinking water consumers”
(Gale P. 1996. Developments in microbiological risk assessment models for drinking water- a short review. J Appl Bacteriol 81:403-410)
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Microbial or chemical
pollution of water?
Install treatment
Operational reliability?
Improve operation
• +ve pressure• res chlorine• repair
Distribution system ok?
YES NO
NOYESNO
YES
Microbial risk?
DBPrisk?
Treatment ok
Augment treatment:• disinfection/contact time• improve operation• change disinfectant• BAC/membrane tech., etc.
Augment treatment:• shift point of disinfection• precursor removal• change disinfectant• GAC/BAC etc.• membrane filtration
{Economic constraints at every level
NO
NO
YES
YES
Epidemic/high endemic risk prevention
Low endemic risk prevention
?
? Decision tree
adapted from
Craun GF et al.
1994. Aqua
43:207
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Walkerton, Ontario - 2000
May 12: Torrential downpour washes bacteria from CAFO into well May 17: Complaints of bloody diarrhea, vomiting, cramps, fever May 18: Tests of water sampled May 15 reveal E. coli contamination,
but not notified May 21: Independent testing, boil-water advisory. May 22: First death directly linked to E. coli. May 23: E. coli O157:H7 recognized. Two-year-old girl dies, > 150
people seek hospital treatment, another 500 have symptoms. May 24: Two more die. May 25: Fifth person dies. At least four children in critical condition. May 29: Sixth death.May 30: Seventh death.
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http://www.factoryfarm.org/photogallery1.html#h3
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https://vimeo.com/18382889
Walkerton 5 years on
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https://www.youtube.com/watch?v=DtZ-2O6wyl8
Walkerton water treatment plant