Occurrence of chlorine-resistant Pseudomonas aeruginosa in hospital water systems: threat of waterborne infections for patients.

BACKGROUND: Several healthcare-associated infection outbreaks have been caused by waterborne Pseudomonas aeruginosa exhibiting its ability to colonize water systems and resist conventional chlorine treatment. This study aims to investigate the occurrence of Pseudomonas aeruginosa in hospital drinking water systems and the antimicrobial resistance profiles (antibiotic and chlorine resistance) of isolated strains. METHODS: We investigated the presence of Pseudomonas aeruginosa in water and biofilms developed in nine hospital water systems (n = 192) using culture-based and molecular methods. We further assessed the survival of isolated strains after exposure to 0.5 and 1.5 ppm concentrations of chlorine. The profile of antibiotic resistance and presence of antibiotic resistance genes in isolated strains were also investigated. RESULTS: Using direct PCR method, Pseudomonas aeruginosa was detected in 22% (21/96) of water and 28% (27/96) of biofilm samples. However, culturable Pseudomonas aeruginosa was isolated from 14 samples. Most of P. aeruginosa isolates (86%) were resistant to at least one antibiotic (mainly ß-lactams), with 50% demonstrating multidrug resistance. Moreover, three isolates harbored intI1 gene and two isolates contained blaOXA-24,blaOXA-48, and blaOXA-58| genes. Experiments with chlorine disinfection revealed that all tested Pseudomonas aeruginosa strains were resistant to a 0.5 ppm concentration. However, when exposed to a 1.5 ppm concentration of chlorine for 30 min, 60% of the strains were eliminated. Interestingly, all chlorine-resistant bacteria that survived at 30-minute exposure to 1.5 ppm chlorine were found to harbor the intI1 gene. CONCLUSIONS: The detection of antimicrobial resistant Pseudomonas aeruginosa in hospital water systems raises concerns about the potential for infections among hospitalized patients. The implementation of advanced mitigation measures and targeted disinfection methods should be considered to tackle the evolving challenges within hospital water systems.

Developing a digital data platform for surveillance of food and water-borne pathogens in North East India: insight for public health advocacy.

Robust digital infrastructure is vital and the need of the hour, especially in the healthcare sector, for real-time data generation, analysis, and quick decision-making. Food- and water-borne illnesses represent a prominent cause of morbidity and mortality worldwide. India, a developing nation with diverse cultures and food practices, poses a high risk of food-borne diseases and outbreaks, yet is often underreported and ineffectively researched. Also, the unique socio-economic and environmental factors of the Northeast (NE) region contribute to the high burden of food-borne diseases. To address these trepidations, the Indian Council of Medical Research (ICMR) has undertaken a study for the surveillance of food-borne pathogens in NE India. The present study focuses on the development of a digital database system for the systematic surveillance of foodborne disease outbreaks, aiming to address the gaps in traditional surveillance methods and improve disease detection and response capabilities. The digital system integrates mobile applications, web-based platforms, and advanced analytics tools to enable real-time data collection, dissemination, and analysis of food-borne illness data. Additionally, the secure and scalable nature of the system enhances data accuracy and accessibility, making it a valuable tool for enhancing food-borne disease surveillance efforts in resource-constrained settings.

Canadian beach cohort study: protocol of a prospective study to assess the burden of recreational water illness.

BACKGROUND: Recreational water activities at beaches are popular among Canadians. However, these activities can increase the risk of recreational water illnesses (RWI) among beachgoers. Few studies have been conducted in Canada to determine the risk of these illnesses. This protocol describes the methodology for a study to determine the risk and burden of RWI due to exposure to fecal pollution at beaches in Canada. METHODS: This study will use a mixed-methods approach, consisting of a prospective cohort study of beachgoers with embedded qualitative research. The cohort study involves recruiting and enrolling participants at public beaches across Canada, ascertaining their water and sand contact exposure status, then following-up after seven days to determine the incidence of acute RWI outcomes. We will test beach water samples each recruitment day for culture-based E. coli, enterococci using rapid molecular methods, and microbial source tracking biomarkers. The study started in 2023 and will continue to 2025 at beaches in British Columbia, Manitoba, Ontario, and Nova Scotia. The target enrollment is 5000 beachgoers. Multilevel logistic regression models will be fitted to examine the relationships between water and sand contact and RWI among beachgoers. We will also examine differences in risks by beachgoer age, gender, and beach location and the influence of fecal indicator bacteria and other water quality parameters on these relationships. Sensitivity analyses will be conducted to examine the impact of various alternative exposure and outcome definitions on these associations. The qualitative research phase will include focus groups with beachgoers and key informant interviews to provide additional contextual insights into the study findings. The study will use an integrated knowledge translation approach. DISCUSSION: Initial implementation of the study at two Toronto, Ontario, beaches in 2023 confirmed that recruitment is feasible and that a high completion rate (80%) can be achieved for the follow-up survey. While recall bias could be a concern for the self-reported RWI outcomes, we will examine the impact of this bias in a negative control analysis. Study findings will inform future recreational water quality guidelines, policies, and risk communication strategies in Canada.

Smart waterborne disease control for a scalable population using biodynamic model in IoT network.

We propose a biodynamic model for managing waterborne diseases over an Internet of Things (IoT) network, leveraging the scalability of LoRa IoT technology to accommodate a growing human population. The model, based on fractional order derivatives (FOD), enables smart prediction and control of pathogens that cause waterborne diseases using IoT infrastructure. The human-pathogen-based biodynamic FOD model utilises epidemic parameters (SVIRT: susceptibility, vaccination, infection, recovery, and treatment) transmitted over the IoT network to predict pathogenic contamination in water reservoirs and dumpsites in Iji-Nike, Enugu, the study community in Nigeria. These pathogens contribute to person-to-person, water-to-person, and dumpsite-to-person transmission of disease vectors. Five control measures are proposed: potable water supply, treatment, vaccination, adequate sanitation, and health education campaigns. A stable disease-free equilibrium point is found when the effective reproduction number of the pathogens, R0eff<1 and unstable if R0eff>1. While other studies showed a 98.2% reduction in infections when using IoT alone, this paper demonstrates that combining the SVIRT epidemic control parameters (such as potable water supply and health education campaign) with IoT achieves a 99.89% reduction in infected human populations and a 99.56% reduction in pathogen populations in water reservoirs. Furthermore, integrating treatment with sanitation results in a 99.97% reduction in infected populations. Finally, combining these five control strategies nearly eliminates infection and pathogen populations, demonstrating the effectiveness of multifaceted approaches in public health and environmental management. This study provides a blueprint for governments to plan sustainable smart cities for a growing population, ensuring potable water free from pathogenic contamination,in line with the United Nations Sustainable Development Goals #6 (Clean Water and Sanitation) and #11 (Sustainable Cities and Communities).

Water, environment, and health nexus: understanding the risk factors for waterborne diseases in communities along the Tano River Basin, Ghana.

Freshwater pollution is a major concern in Ghana, directly impacting human health. However, the underlying drivers of exposure and risks are not comprehensively understood, emphasizing the severity and impact of these diseases. This study assessed the interaction between water and human health, specifically focusing on the risk factors for waterborne diseases and the drivers of water pollution among residents near the Tano River Basin, Ghana. A sample size of 400 households was selected from five communities within the basin based on their proximity to the Tano River. In addition, the study combined both spatial and non-spatial data sources to map potential flood zones for the basin. The study found that inadequate sanitation, poor hygiene practices, and contamination from illegal mining were the primary causative factors of waterborne diseases. Additionally, floods and improper waste management significantly contributed to disease outbreaks. The flood susceptibility analysis indicated that areas highly susceptible to flooding cover 21.2% of the basin, predominantly in the southern part. The results highlight the urgent need for comprehensive interventions to address the drivers of waterborne diseases. This study will contribute to the local authorities in developing plans to prevent waterborne diseases and mitigate their economic and public health impacts.

Estimating the risk of gastrointestinal illness associated with drinking tap water in Norway: a prospective cohort study.

BACKGROUND: The delivery of safe drinking water has high public health relevance, as reflected in the Sustainable Development Goals (SDG6). Several precautionary actions have reduced the burden associated with infectious diseases in high-income countries; however, pollution in source waters, inadequate disinfection, and premise plumbing, along with an increased awareness that intrusion in the drinking water distribution system, represents risk factors for gastrointestinal illness linked to consume of drinking water. Sporadic cases of waterborne infections are expected to be underreported since a sick person is less likely to seek healthcare for a self-limiting gastrointestinal infection. Hence, knowledge on the true burden of waterborne diseases is scarce. The primary aim with the present study was to estimate the risk of gastrointestinal illness associated with drinking tap water in Norway. METHODS: We conducted a 12-month prospective cohort study where participants were recruited by telephone interview after invitation based on randomised selection. A start up e-survey were followed by 12 monthly SMS questionnaires to gather information on participants characteristics and drinking tap water (number of 0.2L glasses per day), incidence, duration and symptoms associated with gastrointestinal illness. Associations between the exposure of drinking tap water and the outcome of risk of acute gastrointestinal illness (AGI) were analysed with linear mixed effects models. Age, sex, education level and size of the drinking water supply were identified as potential confounders and included in the adjusted model. RESULTS: In total, 9,946 persons participated in this cohort study, accounting for 11.5% of all invited participants. According to the data per person and month (99,446 monthly submissions), AGI was reported for 5,508 person-months (5.5 per 100 person-months). Severe AGI was reported in 819 person-months (0.8 per 100 person-months). Our study estimates that 2-4% of AGI in Norway is attributable to drinking tap water. CONCLUSIONS: This is the largest cohort study in Norway estimating the burden of self-reported gastrointestinal infections linked to the amount of tap water drunk in Norway. The data indicate that waterborne AGI is not currently a burden in Norway, but the findings need to be used with caution. The importance of continued efforts and investments in the maintenance of drinking water supplies in Norway to address the low burden of sporadic waterborne cases and to prevent future outbreaks needs to be emphasised.

Too much ado about data: continuous remote monitoring of water temperatures, circulation and throughput can assist in the reduction of hospital-associated waterborne infections.

BACKGROUND: National and international guidance provides advice on maintenance and management of water systems in healthcare buildings; however, healthcare-associated waterborne infections (HAWIs) are increasing. AIM: To identify parameters critical to water quality in healthcare buildings and to assess whether remote sensor monitoring can deliver safe water systems, thus reducing HAWIs. METHODS: A narrative review was performed using the following search terms: (1) consistent water temperature AND waterborne pathogen control OR nosocomial infection; (2) water throughput AND waterborne pathogen control OR nosocomial infection; (3) remote monitoring of in-premises water systems AND continuous surveillance for temperature OR throughput OR flow OR use. Databases employed were PubMed, CDSR (Clinical Study Data Request) and DARE (Database of Abstracts of Reviews of Effects) from January 2013 to March 2024. FINDINGS: Single ensuite-patient rooms, expansion of handwash basins, widespread glove use, alcohol gel and wipes have increased water system stagnancy resulting in amplification of waterborne pathogens and transmission risk of legionella, pseudomonas, and non-tuberculous mycobacteria. Manual monitoring does not represent temperatures across large complex water systems. This review deems that multiple-point continuous remote sensor monitoring is effective at identifying redundant and low use outlets, hydraulic imbalance and inconsistent temperature delivery across in-premises water systems. CONCLUSION: As remote monitoring becomes more common there will be greater recognition of failures in temperature control, hydraulics, and balancing in water systems, and there remains much to learn as we adopt this developing technology within our hospitals.

Impacts of climate change on water-related mosquito-borne diseases in temperate regions: A systematic review of literature and meta-analysis.

Mosquito-borne diseases are a known tropical phenomenon. This review was conducted to assess the mecha-nisms through which climate change impacts mosquito-borne diseases in temperate regions. Articles were searched from PubMed, Scopus, Web of Science, and Embase databases. Identification criteria were scope (climate change and mosquito-borne diseases), region (temperate), article type (peer-reviewed), publication language (English), and publication years (since 2015). The WWH (who, what, how) framework was applied to develop the research question and thematic analyses identified the mechanisms through which climate change affects mosquito-borne diseases. While temperature ranges for disease transmission vary per mosquito species, all are viable for temperate regions, particularly given projected temperature increases. Zika, chikungunya, and dengue transmission occurs between 18-34 °C (peak at 26-29 °C). West Nile virus establishment occurs at monthly average temperatures between 14-34.3 °C (peak at 23.7-25 °C). Malaria establishment occurs when the consecutive average daily temperatures are above 16 °C until the sum is above 210 °C. The identified mechanisms through which climate change affects the transmission of mosquito-borne diseases in temperate regions include: changes in the development of vectors and pathogens; changes in mosquito habitats; extended transmission seasons; changes in geographic spread; changes in abundance and behaviors of hosts; reduced abundance of mosquito predators; interruptions to control operations; and influence on other non-climate factors. Process and stochastic approaches as well as dynamic and spatial models exist to predict mosquito population dynamics, disease transmission, and climate favorability. Future projections based on the observed relations between climate factors and mosquito-borne diseases suggest that mosquito-borne disease expansion is likely to occur in temperate regions due to climate change. While West Nile virus is already established in some temperate regions, Zika, dengue, chikungunya, and malaria are also likely to become established over time. Moving forward, more research is required to model future risks by incorporating climate, environmental, sociodemographic, and mosquito-related factors under changing climates.

Machine learning and explainable artificial intelligence for the prevention of waterborne cryptosporidiosis and giardiosis.

Cryptosporidium and Giardia are important parasitic protozoa due to their zoonotic potential and impact on human health, and have often caused waterborne outbreaks of disease. Detection of (oo)cysts in water matrices is challenging and extremely costly, thus only few countries have legislated for regular monitoring of drinking water for their presence. Several attempts have been made trying to investigate the association between the presence of such (oo)cysts in waters with other biotic or abiotic factors, with inconclusive findings. In this regard, the aim of this study was the development of an holistic approach leveraging Machine Learning (ML) and eXplainable Artificial Intelligence (XAI) techniques, in order to provide empirical evidence related to the presence and prediction of Cryptosporidium oocysts and Giardia cysts in water samples. To meet this objective, we initially modelled the complex relationship between Cryptosporidium and Giardia (oo)cysts and a set of parasitological, microbiological, physicochemical and meteorological parameters via a model-agnostic meta-learner algorithm that provides flexibility regarding the selection of the ML model executing the fitting task. Based on this generic approach, a set of four well-known ML candidates were, empirically, evaluated in terms of their predictive capabilities. Then, the best-performed algorithms, were further examined through XAI techniques for gaining meaningful insights related to the explainability and interpretability of the derived solutions. The findings reveal that the Random Forest achieves the highest prediction performance when the objective is the prediction of both contamination and contamination intensity with Cryptosporidium oocysts in a given water sample, with meteorological/physicochemical and microbiological markers being informative, respectively. For the prediction of contamination with Giardia, the eXtreme Gradient Boosting with physicochemical parameters was the most efficient algorithm, while, the Support Vector Regression that takes into consideration both microbiological and meteorological markers was more efficient for evaluating the contamination intensity with cysts. The results of the study designate that the adoption of ML and XAI approaches can be considered as a valuable tool for unveiling the complicated correlation of the presence and contamination intensity with these zoonotic parasites that could constitute, in turn, a basis for the development of monitoring platforms and early warning systems for the prevention of waterborne disease outbreaks.

Evaluating water-related health risks in East and Central Asian Islamic Nations using predictive models (2020-2030).

This paper presents a thorough evaluation of health outcomes linked to water-related challenges in Islamic nations across East Asia and Central Asia from 2020 to 2030. It has been examined carefully that the trajectory of deaths and disability-adjusted life years associated with unsafe water sources, lack of sanitation, and absence of handwashing facilities is showing a potential rise in negative health impacts due to water pollution. The direct health influences of water-related problems are thoughtful. The increase in deaths and DALYs due to poor water quality and sanitation leads to a higher occurrence of waterborne diseases such as cholera, diarrhea, and dysentery. These conditions not only cause instant health disasters but also subsidize to long-term health issues which include chronic gastrointestinal disorders and malnutrition that is particularly among susceptible populations like children and the elderly. Employing various predictive models including autoregressive integrated moving average, exponential smoothing, support vector machines, and neural networks. The study evaluates their predictive capabilities by using mean absolute percentage error. Support vector machines is found to be the most accurate in forecasting deaths and disability-adjusted life years which is outperforming autoregressive integrated moving average, exponential smoothing, and neural networks. This research aims to inform stakeholders by providing insights into effective strategies for improving water resource management and public health interventions in the targeted regions.

The impact of sink removal and other water-free interventions in intensive care units on water-borne healthcare-associated infections: a systematic review.

With increasing awareness of water sinks as potential sources of outbreaks and transmission of multi-drug resistant (MDR) bacteria in intensive care units (ICUs), there is growing interest in water-free patient care systems. This systematic review reviewed and synthesized available evidence on the effectiveness of sink removal with or without water-free activities in the ICU environment to reduce water-borne healthcare-associated infections. We searched five databases (PubMed, MEDLINE, Scopus, Web of Science and Embase) for studies published from 1st January 1980 to 2nd April 2024 that examined water-less or water-free activities in the ICU to reduce healthcare-associated infections and patient colonization. Of 2075 articles, seven quasi-experimental studies (total: 332 patient beds) met the study selection criteria. Six of these seven studies (85.7%) were based in adult ICUs; one (14%) was in a neonatal ICU. Five of seven sites (71.4%) implemented water-less interventions after an outbreak. Water-free alternatives used included water-less bath products (six of seven; 85.7%), bottled water for consumption (three of seven; 42.9%), oral care (three of seven; 42.9%) and dissolving of oral medication (four of seven; 57.1%), designated 'contaminated' sink outside of patient and medication preparation areas for disposal of wastewater (four of seven; 57.1%). Implicated pathogens studied included MDR Gram-negative bacteria (four of seven; 57.1%), MDR Pseudomonas aeruginosa only (two of seven; 28.6%), and pulmonary non-tuberculous mycobacterium (NTB) (one of seven; 14.3%). Five of seven (71.4%) studies reported outbreak cessation. Preliminary evidence, from a limited number of studies of which the majority were conducted in an outbreak setting, suggest that sink removal and other water-free interventions in the ICU helped terminate outbreaks involving taps and decrease hospital-onset respiratory isolation of pulmonary NTB.

Gastroenteritis Outbreaks after Contamination of Water Supply Systems: Public Health Response Gaps and Challenges, Greece, 2004-2023.

BACKGROUND: waterborne disease outbreaks (WGDOs) following the contamination of drinking water remain a public health concern. METHODS: The current study aims to assess the occurrence and identify gaps in the notification and investigation of WGDOs in Greece. Data for 2004-2023 were retrieved and summarized. RESULTS: Thirty-five outbreaks with 6128 recorded cases were identified. The median time from the date of onset in the first cases to reporting was 7 days (range: 1-26 days). Authorities were informed by health care services in thirty (85.7%) outbreaks and by the media in five (14.3%). The investigation methods used varied. An analytical study was conducted in nine (25.7%) outbreaks and the testing of clinical samples in twenty-seven (77.1%). In three (11.1%) outbreaks, clinical samples were simultaneously tested for multiple bacteria, viruses, and parasites. Water samples were collected in nineteen (54.3%) outbreaks (in three after chlorination) with a mean time lag of 5 days (range: 1-20 days) from the first cases. A pathogen in clinical samples was identified in 20 (57.1%) outbreaks and, in 1 (6.25%), the same microorganism was isolated in both clinical and water samples. CONCLUSIONS: delays in reporting and the heterogeneity of investigations depict that the surveillance of WGDOs and response practices should be strengthened, and operational procedures should be standardised.

Clostridium and Cryptosporidium outbreak linked to a splash pad.

BACKGROUND: . Splash pads for recreational purposes are widespread. Using these pads can pose a health risk if they lack installation regulation and water quality supervision. Our aim was to describe a waterborne disease outbreak caused by Clostridium perfringens and Cryptosporidium spp. in a Barcelona district and the measures taken for its control. METHODS: . On August 2018, 71 cases of acute gastroenteritis were detected, affecting people who used a splash pad or were in contact with a user. Microbiological and environmental investigations were carried out. A descriptive analysis of the sample and Poisson regression models adjusted for age and sex were performed, obtaining frequencies, median values, and adjusted prevalence ratios with their 95% confidence intervals. RESULTS: The median age of the cases was 6.7 years, 27 (38%) required medical care, and three (4.2%) were hospitalized. The greater the number of times a person entered the area, the greater the number of symptoms and their severity. Nineteen (76%) of the 25 stool samples collected from cases showed the presence of one or both pathogens. Environmental investigations showed deficiencies in the facilities and identified the presence of both species in the splash pad. Health education and hygiene measures were carried out, and 14 days after the closure of the facilities, no more cases related to the pad were recorded. CONCLUSIONS: . Specific regulations are needed on the use of splash pads for recreational purposes. Until these regulations are in place, these types of facility should comply with the regulations that apply to swimming pools and spas, including those related to the design of the tanks, water recirculation systems, and adequate disinfection systems.

A rare waterborne outbreak of Bacillus paranthracis in Shandong province, China, 2020: epidemiologic survey, genomic insights, and virulence characteristics.

Bacillus paranthracis, a Gram-positive conditional pathogen of Bacillus cereus group species, is capable of causing foodborne and waterborne illnesses, leading to intestinal diseases in humans characterized by diarrhoea and vomiting. However, documented cases of B. paranthracis infection outbreaks are rare in the world, and the genomic background of outbreak strains is seldom characterized. This study retrospectively analyzed strains obtained from an outbreak in schools, as well as from water systems in peri-urban areas, China, in 2020. In total, 28 B. cereus group isolates were retrieved, comprising 6 from stool samples and 22 from water samples. Epidemiological and phylogenetic investigations indicated that the B. paranthracis isolate from drinking water as the causative agent of the outbreak. The genomic comparison revealed a high degree of consistency among 8 outbreak-related strains in terms of antimicrobial resistance gene profiles, virulence gene profiles, genomic content, and multilocus sequence typing (MLST). The strains related to the outbreak show highly similar genomic ring diagrams and close phylogenetic relationships. Additionally, this study shed light on the pathogenic potential and complexity of B. cereus group through its diversity in virulence genes and mice infection model. The findings highlight the usefulness of B. paranthracis genomes in understanding genetic diversity within specific environments and in tracing the source of pathogens during outbreak situations, thereby enabling targeted infection control interventions.

Climate change and its impact on infectious diseases in Asia.

ABSTRACT: Climate change, particularly increasing temperature, changes in rainfall, extreme weather events and changes in vector ecology, impacts the transmission of many climate-sensitive infectious diseases. Asia is the world's most populous, rapidly evolving and diverse continent, and it is already experiencing the effects of climate change. Climate change intersects with population, sociodemographic and geographical factors, amplifying the public health impact of infectious diseases and potentially widening existing disparities. In this narrative review, we outline the evidence of the impact of climate change on infectious diseases of importance in Asia, including vector-borne diseases, food- and water-borne diseases, antimicrobial resistance and other infectious diseases. We also highlight the imperative need for strategic intersectoral collaboration at the national and global levels and for the health sector to implement adaptation and mitigation measures, including responsibility for its own greenhouse gas emissions.

Surveillance of Waterborne Disease Outbreaks Associated with Drinking Water - United States, 2015-2020.

Problem/Condition: Public health agencies in U.S. states, territories, and freely associated states investigate and voluntarily report waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS). This report summarizes NORS drinking water outbreak epidemiologic, laboratory, and environmental data, including data for both public and private drinking water systems. The report presents outbreak-contributing factors (i.e., practices and factors that lead to outbreaks) and, for the first time, categorizes outbreaks as biofilm pathogen or enteric illness associated. Period Covered: 2015-2020. Description of System: CDC launched NORS in 2009 as a web-based platform into which public health departments voluntarily enter outbreak information. Through NORS, CDC collects reports of enteric disease outbreaks caused by bacterial, viral, parasitic, chemical, toxin, and unknown agents as well as foodborne and waterborne outbreaks of nonenteric disease. Data provided by NORS users, when known, for drinking water outbreaks include 1) the number of cases, hospitalizations, and deaths; 2) the etiologic agent (confirmed or suspected); 3) the implicated type of water system (e.g., community or individual or private); 4) the setting of exposure (e.g., hospital or health care facility; hotel, motel, lodge, or inn; or private residence); and 5) relevant epidemiologic and environmental data needed to describe the outbreak and characterize contributing factors. Results: During 2015-2020, public health officials from 28 states voluntarily reported 214 outbreaks associated with drinking water and 454 contributing factor types. The reported etiologies included 187 (87%) biofilm associated, 24 (11%) enteric illness associated, two (1%) unknown, and one (<1%) chemical or toxin. A total of 172 (80%) outbreaks were linked to water from public water systems, 22 (10%) to unknown water systems, 17 (8%) to individual or private systems, and two (0.9%) to other systems; one (0.5%) system type was not reported. Drinking water-associated outbreaks resulted in at least 2,140 cases of illness, 563 hospitalizations (26% of cases), and 88 deaths (4% of cases). Individual or private water systems were implicated in 944 (43%) cases, 52 (9%) hospitalizations, and 14 (16%) deaths.Enteric illness-associated pathogens were implicated in 1,299 (61%) of all illnesses, and 10 (2%) hospitalizations. No deaths were reported. Among these illnesses, three pathogens (norovirus, Shigella, and Campylobacter) or multiple etiologies including these pathogens resulted in 1,225 (94%) cases. The drinking water source was identified most often (n = 34; 7%) as the contributing factor in enteric disease outbreaks. When water source (e.g., groundwater) was known (n = 14), wells were identified in 13 (93%) of enteric disease outbreaks.Most biofilm-related outbreak reports implicated Legionella (n = 184; 98%); two nontuberculous mycobacteria (NTM) (1%) and one Pseudomonas (0.5%) outbreaks comprised the remaining. Legionella-associated outbreaks generally increased over the study period (14 in 2015, 31 in 2016, 30 in 2017, 34 in 2018, 33 in 2019, and 18 in 2020). The Legionella-associated outbreaks resulted in 786 (37%) of all illnesses, 544 (97%) hospitalizations, and 86 (98%) of all deaths. Legionella also was the outbreak etiology in 160 (92%) public water system outbreaks. Outbreak reports cited the premise or point of use location most frequently as the contributing factor for Legionella and other biofilm-associated pathogen outbreaks (n = 287; 63%). Legionella was reported to NORS in 2015 and 2019 as the cause of three outbreaks in private residences (2). Interpretation: The observed range of biofilm and enteric drinking water pathogen contributing factors illustrate the complexity of drinking water-related disease prevention and the need for water source-to-tap prevention strategies. Legionella-associated outbreaks have increased in number over time and were the leading cause of reported drinking water outbreaks, including hospitalizations and deaths. Enteric illness outbreaks primarily linked to wells represented approximately half the cases during this reporting period. This report enhances CDC efforts to estimate the U.S. illness and health care cost impacts of waterborne disease, which revealed that biofilm-related pathogens, NTM, and Legionella have emerged as the predominant causes of hospitalizations and deaths from waterborne- and drinking water-associated disease. Public Health Action: Public health departments, regulators, and drinking water partners can use these findings to identify emerging waterborne disease threats, guide outbreak response and prevention programs, and support drinking water regulatory efforts.

Infectious Diseases in a Changing Climate.

This JAMA Insights in the Climate Change and Health series discusses the importance of clinicians having awareness of changes in the geographic range, seasonality, and intensity of transmission of infectious diseases to help them diagnose, treat, and prevent these diseases.

The association between climatic factors and waterborne infectious outbreaks with a focus on vulnerability in Pakistan: integrative review.

Climate change affects the spread of waterborne infectious diseases, yet research on vulnerability to outbreaks remains limited. This integrative review examines how climate variables (temperature and precipitation) relate to human vulnerability factors in Pakistan. By 2060, mean temperatures are projected to rise from 21.68°C (2021) to 30°C, with relatively stable precipitation. The epidemiological investigation in Pakistan identified Diarrhea (119,000 cases/year), Malaria (2.6 million cases/year), and Hepatitis (A and E) as the most prevalent infections. This research highlighted vulnerability factors, including poverty (52% of the population), illiteracy (59% of the population), limited healthcare accessibility (55% of the population), malnutrition (38% of the population), dietary challenges (48% of the population), as well as exposure to water pollution (80% of the population) and air pollution (55% of the population). The findings suggest that the coordinated strategies are vital across health, environmental, meteorological, and social sectors, considering climatic variability patterns and population vulnerability determinants.

Waterborne Diseases and Wastewater Treatment in Iraq.

Iraq is a desert country with access to large river resources and an extensive aquifer, but these have already been overdrawn for domestic, industry and agriculture use. The diminished flow of the Tigris and Euphrates rivers has allowed seawater intrusion from the Persian Gulf 110 km up as far as Basra, the county's third largest city. In addition, water distribution systems are overloaded and wastewater treatment plants (WWTPs) need upgrading, and fresh water sources polluted by lack of sanitation, agricultural runoff, household and industrial waste, and including the irrigation of vegetables with sewage water, have led to episodes of bacterial, viral and parasitic diseases. Also, there have been increases in many types of cancer since the early 1990s, and based on clinical and epidemiological data, these increases could be attributable to exposure to depleted uranium in the environment arising from conflict in Iraq and particularly during the Iraqi War started 20 years ago. The population affected would like government action to reduce their health concerns, and policies that have been proposed for improving water availability and quality, as well as but have not been followed up sufficiently to tackle these, including increasing the capacity and efficiency of WWTP; promoting the most efficient irrigation techniques for the local growing conditions; reducing the use of chemical fertilizers and pesticides that can decrease the water quality; reducing saline intrusion challenges; building compact desalination units; constructing water storage facilities to address water scarcity challenges; and establishing public education plans for consumers to reduce the water demand during the hot season. Whether the government rises to the task remains to be seen. Also, do those countries that used the DU have a responsibility to remove or otherwise dispose of the fragments that remain?