Amoueyan E, Ahmad S, Eisenberg JNS, Pecson B, Gerrity D. Quantifying pathogen risks associated with potable reuse: A risk assessment case study for Cryptosporidium. Water research 2017 Apr 19;119:252-266. doi: 10.1016/j.watres.2017.04.048.
This study evaluated the reliability and equivalency of three different potable reuse paradigms: (1) surface water augmentation via de facto reuse with conventional wastewater treatment; (2) surface water augmentation via planned indirect potable reuse (IPR) with ultrafiltration, pre-ozone, biological activated carbon (BAC), and post-ozone; and (3) direct potable reuse (DPR) with ultrafiltration, ozone, BAC, and UV disinfection. A quantitative microbial risk assessment (QMRA) was performed to (1) quantify the risk of infection from Cryptosporidium oocysts; (2) compare the risks associated with different potable reuse systems under optimal and sub-optimal conditions; and (3) identify critical model/operational parameters based on sensitivity analyses. The annual risks of infection associated with the de facto and planned IPR systems were generally consistent with those of conventional drinking water systems [mean of (9.4 ± 0.3) × 10-5 to (4.5 ± 0.1) × 10-4], while DPR was clearly superior [mean of (6.1 ± 67) × 10-9 during sub-optimal operation]. Because the advanced treatment train in the planned IPR system was highly effective in reducing Cryptosporidium concentrations, the associated risks were generally dominated by the pathogen loading already present in the surface water. As a result, risks generally decreased with higher recycled water contributions (RWCs). Advanced treatment failures were generally inconsequential either due to the robustness of the advanced treatment train (i.e., DPR) or resiliency provided by the environmental buffer (i.e., planned IPR). Storage time in the environmental buffer was important for the de facto reuse system, and the model indicated a critical storage time of approximately 105 days. Storage times shorter than the critical value resulted in significant increases in risk. The conclusions from this study can be used to inform regulatory decision making and aid in the development of design or operational criteria for IPR and DPR systems.
Mahon M, Doyle S. Waterborne outbreak of cryptosporidiosis in the South East of Ireland: weighing up the evidence. Ir J Med Sci. 2017 Jan 13. doi: 10.1007/s11845-016-1552-1.
BACKGROUND: In late Spring 2012, 12 cases of cryptosporidiosis in a town in the South East of Ireland were notified to the regional Department of Public Health.
AIM: The purpose of this paper is to describe the outbreak and the investigative process which led to the conclusion that the source was a public drinking water supply.
METHODS: Outbreak and incident control teams were convened to investigate and control the outbreak.
RESULTS: Eleven cases were speciated as Cryptosporidium parvum. GP60 analysis demonstrated that 10 were C. parvum IIaA20G3R1, indicating that the cases were linked. The public water supply was the only common risk factor identified. Increased water sampling identified Cryptosporidium muris/andersoni in the treated water at one of two water treatment plants (Water Treatment Plant, WTP A) for the supply, and on the network. C. parvum was subsequently identified in raw water from WTP A.
CONCLUSIONS: The Health Service Executive (HSE) concluded that this outbreak was “probably associated with water” produced at WTP A based on (1) descriptive epidemiological evidence suggesting water-related illness and excluding other obvious explanations; and (2) water treatment failure at WTP A. WTP A was closed to facilitate an upgrade. No boil water notice was required as a supplementary supply was available. The upgrade was completed and the incident closed in 2013.
A whole flock of epidemiologists fly in to discover the cause of a cryptosporidiosis outbreak, only to find what has been known for more than 3 decades. The appropriate water treatment processes must be in place to remove cryptosporidium if present in a source water other wise cryptosporidium happens. Watershed protection efforts can help but not ensure that these events will not happen. Just writing more federal and state regulations does not prevent waterborne disease outbreaks. Responsible planning, vigilance, and action at the local level is what it takes.
DeSILVA MB, Schafer S, Kendall Scott M, Robinson B, Hills A, Buser GL, Salis K, Gargano J, Yoder J, Hill V, Xiao L, Roellig D, Hedberg K. Communitywide cryptosporidiosis outbreak associated with a surface water-supplied municipal water system – Baker City, Oregon, 2013. Epidemiology and Infection. 2015 Aug 12:1-11.
Cryptosporidium, a parasite known to cause large drinking and recreational water outbreaks, is tolerant of chlorine concentrations used for drinking water treatment. Human laboratory-based surveillance for enteric pathogens detected a cryptosporidiosis outbreak in Baker City, Oregon during July 2013 associated with municipal drinking water. Objectives of the investigation were to confirm the outbreak source and assess outbreak extent. The watershed was inspected and city water was tested for contamination. To determine the community attack rate, a standardized questionnaire was administered to randomly sampled households. Weighted attack rates and confidence intervals (CIs) were calculated. Water samples tested positive for Cryptosporidium species; a Cryptosporidium parvum subtype common in cattle was detected in human stool specimens. Cattle were observed grazing along watershed borders; cattle faeces were observed within watershed barriers. The city water treatment facility chlorinated, but did not filter, water. The community attack rate was 28·3% (95% CI 22·1-33·6), sickening an estimated 2780 persons. Watershed contamination by cattle probably caused this outbreak; water treatments effective against Cryptosporidium were not in place. This outbreak highlights vulnerability of drinking water systems to pathogen contamination and underscores the need for communities to invest in system improvements to maintain multiple barriers to drinking water contamination.
Bichai F, Dullemont Y, Hijnen W, Barbeau B. Predation and transport of persistent pathogens in GAC and slow sand filters: A threat to drinking water safety? Water Res. 2014 Jul 17;64C:296-308. doi: 10.1016/j.watres.2014.07.005.
Zooplankton has been shown to transport internalized pathogens throughout engineered drinking water systems. In this study, experimental measurements from GAC and SSF filtration tests using high influent concentrations of Cryptosporidium (1.3 × 106 and 3.3 × 104 oocysts L-1) and Giardia (4.8 × 104 cysts L-1) are presented and compared. A predation and transport conceptual model was developed to extrapolate these results to environmental conditions of typical (oo)cyst concentrations in surface water in order to predict concentrations of internalized (oo)cysts in filtered water. Pilot test results were used to estimate transport and survival ratios of internalized (oo)cysts following predation by rotifers in the filter beds. Preliminary indications of lower transport and survival ratios in SSF were found as compared with GAC filters. A probability of infection due to internalized (oo)cysts in filtered water was calculated under likeliest environmental conditions and under a worst-case scenario. Estimated risks under the likeliest environmental scenario were found to fall below the tolerable risk target of 10-4 infections per person per year. A discussion is presented on the health significance of persistent pathogens that are internalized by zooplankton during granular filtration processes and released into treated water.
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Puleston RL, Mallaghan CM, Modha DE, Hunter PR, Nguyen-Van-Tam JS, Regan CM, Nichols GL, Chalmers RM. The first recorded outbreak of cryptosporidiosis due to Cryptosporidium cuniculus (formerly rabbit genotype), following a water quality incident. J Water Health. 2014 Mar;12(1):41-50. doi: 10.2166/wh.2013.097.
We report the first identified outbreak of cryptosporidiosis with Cryptosporidium cuniculus following a water quality incident in Northamptonshire, UK. A standardised, enhanced Cryptosporidium exposure questionnaire was administered to all cases of cryptosporidiosis after the incident. Stool samples, water testing, microscopy slides and rabbit gut contents positive for Cryptosporidium were typed at the Cryptosporidium Reference Unit, Singleton Hospital, Swansea. Twenty-three people were microbiologically linked to the incident although other evidence suggests an excess of 422 cases of cryptosporidiosis above baseline. Most were adult females; unusually for cryptosporidiosis there were no affected children identified under the age of 5 years. Water consumption was possibly higher than in national drinking water consumption patterns. Diarrhoea duration was negatively correlated to distance from the water treatment works where the contamination occurred. Oocyst counts were highest in water storage facilities. This outbreak is the first caused by C. cuniculus infection to have been noted and it has conclusively demonstrated that this species can be a human pathogen. Although symptomatically similar to cryptosporidiosis from C. parvum or C. hominis, this outbreak has revealed some differences, in particular no children under 5 were identified and females were over-represented. These dissimilarities are unexplained although we postulate possible explanations.
Pollock KG, Young D, Robertson C, Ahmed S, Ramsay CN. Reduction in cryptosporidiosis associated with introduction of enhanced filtration of drinking water at Loch Katrine, Scotland. Epidemiol Infect. 2013 Apr 16:1-7.
SUMMARY Previous evidence has suggested an association between cryptosporidiosis and consumption of unfiltered drinking water from Loch Katrine in Scotland. Before September 2007, the water was only micro-strained and chlorinated; however, since that time, coagulation and rapid gravity filtration have been installed. In order to determine risk factors associated with cryptosporidiosis, including drinking water, we analysed data on microbiologically confirmed cases of cryptosporidiosis from 2004 to 2010. We identified an association between the incidence of cryptosporidiosis and unfiltered Loch Katrine drinking water supplied to the home (odds ratio 1·86, 95% confidence interval 1·11-3·11, P = 0·019). However, while filtration appears to be associated with initially reduced rates of cryptosporidiosis, evidence suggests it may paradoxically make those consumers more susceptible to other transmission routes in the long-term. These findings support implementation of similar treatment for other unfiltered drinking-water supplies, as a means of reducing cryptosporidiosis associated with drinking water.
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Guosheng Xiao, Zhiqun Qiu, Junsheng Qi, Ji-an Chen, Fengdan Liu, Wenyi Liu, Jiaohua Luo, Weiqun Shu. Occurrence and potential health risk of Cryptosporidium and Giardia in the Three Gorges Reservoir, China. Water Research, Volume 47, Issue 7, 1 May 2013, Pages 2431–2445.
The Three Gorges Reservoir (TGR) is the biggest lake in the world and a major water source in China. There is no information about occurrence and impact of Cryptosporidium and Giardia on the aquatic ecosystem. 61 surface water samples from 23 monitoring sites and 5 treated effluent samples were collected and analyzed. Cryptosporidium oocysts and Giardia cysts were found, respectively, in 86.4% and 65.2% of a total of 66 water samples, with high concentrations in treated effluent. The mean percent recovery was 29.14% for oocysts and 34.86% for cysts. A seasonal pattern was observed, with positive samples for Cryptosporidium more frequent in flood period and positive samples for Giardia more frequent in impounding period. Counts of enterococci, fecal coliforms and total coliforms, and turbidity were significantly associated with Cryptosporidium concentration in backwater (water in a main river which is backed up by the Three Gorges Dam) areas of tributaries but not Giardia. High associations were also found between oocyst and cyst in backwater areas of tributaries and cities. The risks of infection and illness due to water consumption in four different exposure routes were estimated. The results showed that swimming in the TGR has the highest infection risk with 1.39 × 10−3 per time (95% confidence interval (CI): 0.05–600.3 × 10−5) for Cryptosporidium and 2.08 × 10−4 per time (95% CI: 0.05–878.87 × 10−6) for Giardia, while directly drinking unboiled tap water treated with the conventional process has the highest morbidity with 524.98 per 100,000 population per year (95% CI: 10.35–2040.26) for Cryptosporidium and 5.89 per 100,000 population per year (95% CI: 0.08–22.67) for Giardia. This study provides new useful information for drinking water plants, health care workers and managers to improve the safety of tap water and deduce the risk of surface water contamination in China.
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