Educational Workshop EW17: Just when you thought it was safe to go back in the water: leisure-associated water-borne infections arranged with the ESCMID Food- and Waterborne Infections Study Group (EFWISG) Convenors: Paul Hunter (Norwich, UK) Maria José Figueras (Reus, ES) Faculty: Paul Hunter (Norwich, UK) Nicholas Beeching (Liverpool, UK; no presentation submitted) Tim Inglis (Nedlands, AU) Maria José Figueras (Reus, ES)
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections Just when you thought it was safe to go back in the water: leisure associated water borne infections Paul R Hunter The Norwich School of Medicine University of East Anglia Declaration of interests Acted as medical expert witness in relation to travel and waterborne illnesses on multiple times. Served as chair of Science Advisory Committee of Suez Environment up to 2010 Also I would like to make it clear that none of the images of swimming pools used in this slide were associated with poor maintenance or episodes of human illness (as far as I am aware). 3
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections Recreational water exposure is common in UK In a telephone survey of some 16,000 people 9.8% reported having been swimming in a swimming pool in the previous week 0.3% reported swimming in freshwater * 1.3% reported swimming in marine water * * About twice this for summer months (June to September) Slide left blank for copyright reasons How do we know what are and what are not important microbial hazards? Outbreaks of disease Human epidemiological studies Quantitative Microbial Risk Assessment 4
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections Number of recreational water associated outbreaks, by year and illness United States, 1978 2006 MMWR 2008 Number of US recreational water outbreaks by type of water MMWR 2008 Recreational water associated outbreaks of gastroenteritis, by type of exposure and etiologic agent United States, 1997 2006 MMWR 2008 5
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections 16 14 12 10 Swimming pool outbreak of Cryptosporidium England and Wales 8 6 4 2 0 Chalmers 2011 Common themes in cause of outbreaks Inadequate maintenance Breakdowns of equipment Low disinfectant levels or poor filtration Not using UV or ozonation Inadequate water quality monitoring Inadequatelytrained trained staff (faecal incidents) Lack of awareness by the general public of appropriate healthy swimming behaviours. High bather loads during large events Lack of communication within and between public health agencies Outbreaks occurring on weekends Adapted from MMWR 2008 The pathogens Pathogen Treated water Freshwater Cryptosporidium +++ + Norovirus + ++ Unknown cause + ++ E. Coli (EHEC) +/ ++ Shigella sp. +/ ++ Giardia +/ +/ 6
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections BUT WHAT ABOUT SPORADIC DISEASE Tri County Comprehensive Assessment of Risk Factors for Sporadic Reportable Bacterial Enteric Infection in Children Pathogen Exposure OR Campylobacter Any 2.7 (1.5 4.8) Play in kiddie or wading 3.1 (1.4 6.7) pool Play in natural source of 3.4 (1.4 8.4) water E. coli O157 Any 7.4 (2.1 26.1) Salmonella Play in natural source of 28.3 (7.2 112.2) water Shigella Play in natural source of water 14.5 (1.5 141.0) Denno et al. 2009 Case control studies of giardiasis and recreational water * exposure Study location OR Isaac Renton 1992 British Columbia N.S Dennis 1993 New Hampshire 4.6 (2.4 86.0) Mitchell 1993 New Zealand N.S Warburton 1994 East Anglia N.S Gray 1994 Avon & Somerset 2.4 (1.0 6.1) Hoque 2002 New Zealand 2.4 (1.1 5.3) Stuart 2003 SW England 5.5 (1.9 15.9) Espelage 2010 Germany N.S * Fresh surface water 7
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections Case control studies of cryptosporidiosis recreational water * exposure Study location OR Robertson 2002a Melbourne 2.7 (1.9 3.8) Robertson 2002b Adelaide 1.2 (0.8 1.9) Roy 2004 US * 1.9 (1.0 3.5) Hunter 2004 NW England and N.S. Wales Pintar 2009 Ontario * 2.9 (1.2 7.4) * Fresh surface water Case control studies of STEC and recreational water exposure Study location OR McPherson 2009 Australia N.S. Voetsch 2007 US N.S. Kassenborg 2004 US NS N.S. Rivas 2003 Argentina N.S. Locking 2001 UK N.S. * Fresh surface water Case control studies of Norovirus and recreational water exposure Study location OR Fretz 2005 Switzerland N.S. de Wit Netherlands N.S. * Fresh surface water 8
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections So what is so special about America? Effective infectious disease surveillance High levels of recreation in freshwater lakes In some States levels of waste water treatment and discharge exist that would be consider illegal under European Legislation. BUT WHAT ABOUT SELF REPORTED ENDEMIC ILLNESS Figure from Kay study 9
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections A freshwater study Reproduced with permission from Environmental Health Perspectives Wiedenmann 2005 Beach Uses Often Sometimes % Rarely Never Economics for the Environment Consultancy Ltd 2002 Disease burden from marine bathing in England and Wales Exposure Episodes/yr 95% Confidence Intervals For swim/dip 1.3 million (0.75 1.81 million) For all water sports activities 2.84 million (1.44 4.24 million) Economics for the Environment Consultancy Ltd 2002 10
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections Estimates of PAR from marine bathing in England and Wales Exposure PAR 95% Confidence Intervals For swim/dip 13% (7.5 18.1) 1) For all water sports activities 28.4% (14.4 42.4) Assuming 10 million episodes of GI illness/yr in England and Wales from IID1 Association between recreational water contact and self reported diarrhoea Exposure Relative Risk P (95%CI) Swimming pool 1.00 (0.71 1.40) 1.00 Fresh water 0.77 (0.11 5.48) 0.79 Marine water 0.95 (0.39 2.30) 0.91 Swallow water whilst 1.03 (0.51 2.07) 0.93 swimming Population Attributable Risk Exposure Most likely/% U95%CI/% Swimming pool 0 3.8 Fresh water 0 1.5 Exposure 0 1.8 11
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections So why the discrepancies? Most enteric infections have very short durations of immunity (6 12 months) Norovirus Cryptosporidium Giardia Campylobacter Bathing exposure frequency is highly skewed Impact of daily probability of infection of incidence of illness 0.8 0.6 illness/y P 0.4 0.2 0.0-5.5-5.0-4.5-4.0-3.5-3.0-2.5-2.0-1.5 6 month immunity 12 month immunity Log Pinf/d This is not a reason for not doing anything!!! The immunity effect will not protect people who are not immune Those who are very young and those who go swimming infrequently Prospective epidemiological studies may underestimate risk to those people who only go swimming rarely or are very young 12
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections THE EUROPEAN PACKAGE TRAVEL DIRECTIVE Slide left blank for copyright reasons Conclusions non marine Outbreaks associated with recreational water exposure occur regularly For swimming pools mainly Cryptosporidium For fresh water range of pathogens including norovirus and STEC/EHEC Whether recreational water exposure a main contributor to disease burden depends on local factors 13
Hunter - What's lurking in the lake; what's skulking in the sea? Microbiology of leisure-associated water-borne infections Conclusions marine bathing water There is a significant association between risk of self reported GI and faecal enterococci However, marine bathing does not appear to be a major contributor to population levelsof IID, at least in UK. It is likely that disease risk will fall most heavily on those who swim only infrequently The main issues for diarrhoeal disease and recreation water exposure Failings in pool management Inappropriate bathers behaviour Holiday makers who do not go swimming that often Final conclusions The health risks from bathing are real. However, the benefits of regular swimming substantially outweigh the risks 14
Inglis - Green nails and hot feet: Pseudomonas aeruginosa - a versatile water-borne pathogen 15
Inglis - Green nails and hot feet: Pseudomonas aeruginosa - a versatile water-borne pathogen 16
Inglis - Green nails and hot feet: Pseudomonas aeruginosa - a versatile water-borne pathogen 17
Being wary in the water: preventing leisure-associated water-borne infections Prof. María José Figueras Unit of Microbiology. Department of Health Sciences Faculty of Medicine and Health Sciences University Rovira i Virgili Reus, Spain Excess exposure to the sun Sunburn Dehydration Hypotension Thrombosis Summer health risks Digestive illness Gastroenteritis Salmonellosis Small accidents Cuts/ wounds Bicycle fall. Stings, bites. 18
Objectives: 1. What are the measures established to prevent leisure associated water-borne infections? 2. Are those measures effective? 3. What microbial health threats are we still exposed to? GUIDELINES FOR SAFE RECREATIONAL WATER ENVIRONMENTS Faculty of Medicine University Rovira i Virgili 2000 2002 http://www.who.int/water_sanitation_health/bathing/srwe1/en/ 19
Feces (ill people or asymptomatic carriers) Waste Water Water Resources Feces (ill people or asymptomatic carriers) Waste Water Water Resources WATER CONTAMINATION BY MICROORGANISMS Human faeces Animal faeces Agricultural and livestock activities WWTP Contamination of the water by microorganisms (bacteria, viruses, protozoa) Treatment DWTP Waste water Human activity Waters of lakes, rivers or sea Transmission (ingestion, contact, inhalation) self depuration (T C, salinity, ph, solar irradiation, dilution, physical processes, biotic factors) 20
PATHOGENIC MICROORGANISMS EXCRETED IN FECES AND PRESENT IN CONTAMINATED WATERS Microorganism Excreted quantity by infected person g/feces Maximum surviving in water (days) Infective dose Bacteria E. coli enterotoxigenic 10 8 90 10 9 Salmonella 10 6 60-90 10 Shigella 10 6 30 10 2 Campylobacter 10 7 7 10 6 Vibrio 10 6 30 10 8 Yersinia enterocolitica 10 5 90 10 9 Aeromonas 90 10 8 Virus Enterovirus 10 7 90 100 Hepatitis A 10 6 5-27 Rotavirus 10 6 5-27 Norovirus 5-27 Parasites Entamoeba 10 7 25 10-100 Giardia 10 5 25 5-100 Cryptosporidium Balantidium coli 20 25-100 Ascaris 10 3 365 2-5 Taenia 10 3 270 1 PATHOGENIC MICROORGANISMS EXCRETED IN FECES AND PRESENT IN CONTAMINATED WATERS Microorganism Excreted quantity by infected person g/feces Maximum surviving in water (days) Infective dose Bacteria E. coli enterotoxigenic 10 8 90 10 9 Salmonella 10 6 60-90 10 Shigella 10 6 30 10 2 Campylobacter 10 7 7 10 6 Vibrio 10 6 30 10 8 Yersinia enterocolitica 10 5 90 10 9 Aeromonas 90 10 8 Virus Enterovirus 10 7 90 100 Hepatitis A 10 6 5-27 Rotavirus 10 6 5-27 Norovirus 5-27 Parasites Entamoeba 10 7 25 10-100 Giardia 10 5 25 5-100 Cryptosporidium Balantidium coli 20 25-100 Ascaris 10 3 365 2-5 Taenia 10 3 270 1 WATER CONTAMINATION BY MICROORGANISMS Human faeces Animal faeces Agricultural and livestock activities WWTP Contamination of the water by microorganisms (bacteria, viruses, protozoa) Treatment DWTP Waste water Human activity Waters of lakes, rivers or sea Transmission (ingestion, contact, inhalation) self depuration (T, salinity, ph, solar irradiation, dilution, physical processes, biotic factors) 21
WATER CONTAMINATION BY MICROORGANISMS Human faeces Animal faeces Agricultural and livestock activities WWTP Contamination of the water by microorganisms (bacteria, viruses, protozoa) Treatment DWTP Waste water Human activity Waters of lakes, rivers or sea Transmission (ingestion, contact, inhalation) self depuration (T, salinity, ph, solar irradiation, dilution, physical processes, biotic factors) European Legislation 2006 1976 Directive 76/160/CEE Directive 2006/7/CE OBJECTIVE Protection of the bathing areas through monitoring programmes New Objective More emphasis OBJECTIVE Appropriate management of the water quality Punish Non compliance with standards New philosophy Punish Inaction following non compliance Management Actions have to achieve: 1) Prevention of the risk of bathers being exposed to faecal contamination 2) Reduction and elimination of risks derived from faecal contamination 22
Directive 2006/7/EC 2008 1. Monitoring In force from 24th March 2006 2008 2009 2010 2008 2009 2010 2011 2008-10 2008-11 Excellent Good 2. Bathing water quality assessment and classification Sufficient Poor 95%ile & 90%ile EC and IE 3. Bathing water profiles x 2 1 x * A 5 4 B * 4. Management measures 5. Public participation and information Directive 2006/7/EC Indicators, standards and methods Poor Excellent Good Sufficient Directive 2006/7/EC 2008 1. Monitoring In force from 24th March 2006 2008 2009 2010 2008 2009 2010 2011 2008-10 2008-11 Excellent Good 2. Bathing water quality assessment and classification Sufficient Poor 95%ile & 90%ile EC and IE 3. Bathing water profiles x 2 1 x * A 5 4 B * 4. Management measures 5. Public participation and information 23
Bathing Water Directive 2006/7/EC Bathing water profiles Objective Adequate knowledge of factors affecting water quality Management Aim Actions Poor Excellent Good Sufficient Directive 2006/7/CE Directive 76/160/CEE Faculty of Medicine University Rovira i Virgili 2002 24
France Spain CATALONIA (Spain) Faculty of Medicine University Rovira i Virgili. Reus. Tarragona Barcelona. coastal tourist : 11,000,000 Total area: 32,895 Km 2 Totat coast line: 826 Km Total Population: 7.500.000 inhab. (2010) Catalan monitoring programme for bathing areas 1990-2010 Route 1 Daily control of 240 beaches University Laboratory Route 2 Faculty of Medicine University Rovira i Virgili 17 Beach inspectors Route 3 Analysis of 250 samples Route 4 Route 5 Route 6 Route 7 Sampling Saturday Route 8 Results and diagnosis Route 9 Route 10 Route 11 21 years ca. 85.000 analyses Route 12 Route 13 Total coliforms (TC), Fecal coliforms (FC), E.coli, Route 14 Fecal streptococci= Intestinal enterococci (IE) Catalan monitoring programme for bathing areas Faculty of Medicine University Rovira i Virgili Results of microbiological analysis Wednesday Daily results of the Sanitary and Environmental Inspection Beach classification Very Good Good Poor Very Poor Thursda y Weekly Public Information Public Media Local Authorities 25
MANAGEMENT ACTIONS To bathe or not to bathe SANITARY INSPECTION ACCIDENTS RELATIVE RISK TO HEALTH THROUGH THE EXPOSURE TO SEWAGE OUTFALLS IN BATHING WATERS Type of outfall Type of waste water treatment Direct Short outfall Effective outfall 26
RELATIVE RISK TO HEALTH THROUGH THE EXPOSURE TO SEWAGE OUTFALLS IN BATHING WATERS Effective outfall Low or very low risk October 2010 Combined sewer overflows and storm water discharges 27
Management of rain events 1995 S. Monica Bay Restoration Project Epidemiological study 1/25 people who swim near flowing storm drains will get sick Measures taken: New signs in English and Spanish Allocated $15 million to divert dry-season storm drains to WWTP Public education campaign on health risk of storm water More accurate Beach Pollution Report Card ACTIONS IN CASE OF RAIN WARNING! RAIN WATER CAN PRODUCE DISEASE. DO NO SWIM S. Monica Bay http://www.healthebay.org/stayhealthy/swimming 28
http://www.healthebay.org/stayhealthy/swimming http://www.healthebay.org/stayhealthy/swimming Relative risk to human health through h exposure to bather shedding 29
Relative risk to human health through exposure to bather shedding Chapter 9. Aesthetic issues University Rovira i Virgili La Fosca 28/07/2007 Alexandrinum tailori Faculty of Medicine University Rovira i Virgili Microbiological results 30
http://www.eea.europa.eu/themes/water/status-and-monitoring/state-of-bathing-water-1/state-of-bathing-water 31
Objectives: 1. What are the measures established to prevent leisure associated water-borne infections? 2. Are those measures effective? 3. What microbial health threats are we still exposed to? VI Framework Research Project EPIBATHE Epidemiological Research Study Participants EPIBATHE Institution University of Wales (UWA) National Centre of Public Health (NIH) University Rovira i Virgili (URV) National Public Health Service (NPHS) University of East Anglia (UEA) World Health Organization (WHO) Country UK Hungary Spain UK UK Switzerland 32
2000 participants 2006 & 2007 2006 2007 EPIBATHE Project Total number of final participants 2239 4 Questionaires NON-BATHERS 108 SAMPLES/year BATHERS 2007 33
EPIBATHE Microbiological Results 2239 participants 2006 & 2007 Faculty of Medicine University Rovira i Virgili Results of the 4 epidemiological questionnaires 1st and 2nd interviews Bathers No Bathers Data Base EVALUATION OF RESULTS 2009 3rd interview - 3rd questionnaire 4rth questionnaire BY MAIL!! Data Base CONCLUSIONS Epidemiological Research Study Science Support for Policy Standards of the new Directive 2006/7/EC are adequate to protect human health 34
Objectives: 1. What are the measures established to prevent leisure associated water-borne infections? 2. Are those measures effective? 3. What microbial health threats are we still exposed to? SOME PATHOGENIC MICROORGANISMS EXCRETED IN FECES AND PRESENT IN CONTAMINATED WATERS Are also autochthonous of aquatic environments Microorganism Bacteria E. coli enterotoxigenic Salmonella Shigella Campylobacter Vibrio Yersinia enterocolitica Aeromonas Virus Enterovirus Hepatitis A Cellulitis Rotavirus Norovirus Parasites Entamoeba Giardia Cryptosporidium Balantidium coli Ascaris Taenia Bullae Hemorrhagic bullae Necrotizing fasciitis Environmental sources of Aeromonas species potentially leading to infection or colonization in humans Janda & Abbott 2010 Clin Microbiol Rev 32:35 73 35
Aeromonas wound infections Mud football competition in contact with soil or water 26 patients affected 50% reported systemic symptoms, including fever in 35% of the cases and two patients developed complications that required surgical intervention Faculty of Medicine University Rovira i Virgili TSUNAMI 2004 Aeromonas was the most prevailing bacteria in wound infections 36
Aeromonas was the most isolated bacteria among 305 survivals of the tsunami that showed wound infections No. (%) of isolates (n = 641) Organism Aeromonas species Any species 145 (22.6) Aeromonas hydrophila 104 (16.2) Aeromonas veronii biovar sobria 41 (6.4) Escherichia coli 116 (18.1) Klebsiella pneumoniae 93 (14.5) Pseudomonas aeruginosa 77 (12.0) Proteus species Any species 47 (7.3) Proteus vulgaris 27 (4.2) Proteus mirabilis 20 (3.1) Enterobacter species Any species 42 (6.6) Enterobacter cloacae 28 (4.4) Enterobacter aerogenes 14 (2.2) Acinetobacter calcoaceticus-baumannii 26 (4.1) Morganella morganii 23 (3.6) Serratia marcecens 12 (1.9) Sternotrophomonas maltophilia 10 (1.6) Vibrio species Any species 10 (1.6) Vibrio parahemolyticus 7 (1.1) Vibrio vulnificus 2 (0.3) Vibrio alginolyticus 1 (0.2) Citrobacter species 5 (0.7) Edwardsiella tarda 2 (0.3) Staphylococcus species Any species 17 (2.7) Staphylococcus aureus 11 (1.7) Coagulase-negative 6 (1.0) Enterococcus species Any species 8 (1.3) Enterococcus faecalis 6 (1.0) Enterococcus faecium 2 (0.3) Streptococcus species 3 (0.5) Other a 5 (0.7) Hiransuthikul et al., 2005 Clin Infect Dis. 15:41:e93-6. Total 641 (100.0) Primary septicemia skin lesions caused by Vibrio parahaemolyticus 25/8/2010 A 90-year-old male complaining of fever (39ºC) visited the doctor. Exploration revealed edema in the lower part of the right leg and cellulitis was diagnosed. Empiric antibiotic treatment was initiated with ciprofloxacin and a blood sample was taken for microbiological analysis 2 days later the patient came back because the cellulitis had expanded with bullae and due to the fast evolution he was hospitalized The patient mentioned that 2-3 days before the symptoms started he went to the beach and he noticed a small open wound between the 2nd-3rd toe of the right foot Antibiotic treatment was changed to Ceftriaxone + Cloxacillin iv Vibrio parahaemolyticus Dr. Angeles Ruíz University Hospital Joan XXIII Tarragona Aspect of the right leg at the time of hospitalization 37
Final recovery occurred after 30 days Primary septicemia by Vibrio parahaemolyticus Dr. Angeles Ruíz University Hospital Joan XXIII Tarragona Is the sand a source of infection? ORIGIN OF MICROORGANISMS IN THE SAND 38
Are microbiological analyses required? Faculty of Medicine University Rovira i Virgili Faculty of Medicine University Rovira i Virgili http://www.crid.or.cr/digitalizacion/pdf/spa/doc14617/doc14617-5.pdf 2003 39
2003 2009 European Legislation Recommended Measures RISK OF INFECTION Specific microbe Receptive host 40
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