Characterizing the concentration of Cryptosporidium in Australian surface waters for setting health-based targets for drinking water treatment.

It is proposed that the next revision of the Australian Drinking Water Guidelines will include 'health-based targets', where the required level of potable water treatment quantitatively relates to the magnitude of source water pathogen concentrations. To quantify likely Cryptosporidium concentrations in southern Australian surface source waters, the databases for 25 metropolitan water supplies with good historical records, representing a range of catchment sizes, land use and climatic regions were mined. The distributions and uncertainty intervals for Cryptosporidium concentrations were characterized for each site. Then, treatment targets were quantified applying the framework recommended in the World Health Organization Guidelines for Drinking-Water Quality 2011. Based on total oocyst concentrations, and not factoring in genotype or physiological state information as it relates to infectivity for humans, the best estimates of the required level of treatment, expressed as log10 reduction values, ranged among the study sites from 1.4 to 6.1 log10. Challenges associated with relying on historical monitoring data for defining drinking water treatment requirements were identified. In addition, the importance of quantitative microbial risk assessment input assumptions on the quantified treatment targets was investigated, highlighting the need for selection of locally appropriate values.

History of antimicrobial use and the risk of Dientamoeba fragilis infection.

Associations between antimicrobial use and risk of enteric infection with intestinal protozoa are scarcely studied. The aim of this study was to quantify the risk of Dientamoeba fragilis infection conferred by exposure to antimicrobials. We conducted a registry-based retrospective cohort study of 9,945 Danish patients investigated for D. fragilis infection between 2008 and 2011, using data from the Danish Register of Medicinal Product Statistics, and calculating relative risks (RR) for D. fragilis infection by stratified binary regression. Furthermore, we conducted a population based case-control study using controls sampled from the Danish Civil Registration System, calculating hazard ratios (HR) for D. fragilis infection by conditional logistic regression. Exposure to metronidazole was found to confer decreased risk of D. fragilis infection; however, similar associations were found for antimicrobials not commonly used to treat D. fragilis, such as broad-spectrum penicillin, fluoroquinolones, and macrolides. In contrast, mebendazole exposure was associated with increased risk. The intake of antimicrobials influences the risk of D. fragilis.

Dose-response algorithms for water-borne Pseudomonas aeruginosa folliculitis.

We developed two dose-response algorithms for P. aeruginosa pool folliculitis using bacterial and lesion density estimates, associated with undetectable, significant, and almost certain folliculitis. Literature data were fitted to Furumoto & Mickey's equations, developed for plant epidermis-invading pathogens: N l = A ln(1 + BC) (log-linear model); P inf = 1-e(-r c C) (exponential model), where A and B are 2.51644 × 107 lesions/m2 and 2.28011 × 10-11 c.f.u./ml P. aeruginosa, respectively; C = pathogen density (c.f.u./ml), N l = folliculitis lesions/m2, P inf = probability of infection, and r C = 4·3 × 10-7 c.f.u./ml P. aeruginosa. Outbreak data indicates these algorithms apply to exposure durations of 41 ± 25 min. Typical water quality benchmarks (≈10-2 c.f.u./ml) appear conservative but still useful as the literature indicated repeated detection likely implies unstable control barriers and bacterial bloom potential. In future, culture-based outbreak testing should be supplemented with quantitative polymerase chain reaction and organic carbon assays, and quantification of folliculitis aetiology to better understand P. aeruginosa risks.

Pseudomonas aeruginosa dose response and bathing water infection.

Pseudomonas aeruginosa is the opportunistic pathogen mostly implicated in folliculitis and acute otitis externa in pools and hot tubs. Nevertheless, infection risks remain poorly quantified. This paper reviews disease aetiologies and bacterial skin colonization science to advance dose-response theory development. Three model forms are identified for predicting disease likelihood from pathogen density. Two are based on Furumoto & Mickey's exponential 'single-hit' model and predict infection likelihood and severity (lesions/m2), respectively. 'Third-generation', mechanistic, dose-response algorithm development is additionally scoped. The proposed formulation integrates dispersion, epidermal interaction, and follicle invasion. The review also details uncertainties needing consideration which pertain to water quality, outbreaks, exposure time, infection sites, biofilms, cerumen, environmental factors (e.g. skin saturation, hydrodynamics), and whether P. aeruginosa is endogenous or exogenous. The review's findings are used to propose a conceptual infection model and identify research priorities including pool dose-response modelling, epidermis ecology and infection likelihood-based hygiene management.

Dientamoeba fragilis in Denmark: epidemiological experience derived from four years of routine real-time PCR.

The intestinal protozoon Dientamoeba fragilis remains a clinical entity of dubious significance. While several previous studies address questions of epidemiology, only a handful have systematically employed and reported on the results from real-time polymerase chain reaction (qPCR), the best currently available diagnostic modality, and the comparison of results from different studies is, therefore, difficult. Since 2007, Statens Serum Institut (Denmark) has utilised qPCR for D. fragilis as routine diagnostic work-up for intestinal parasitosis, testing more than 22,000 samples from 2008 through 2011, and the aim of this study was to report on the results and experiences gained in the process. We demonstrate a staggeringly high proportion (43%) of investigated patients positive for D. fragilis, ranging from 12 to 71% depending on age group, showing a bimodal age distribution peaking in children and adults of parental age, as well as a clear association between exposure to children and risk of D. fragilis infection. We discuss these findings in light of the pinworm egg vector hypothesis and substantiate further our knowledge of risk factors pertaining to D. fragilis carriage.

Pathogenic Escherichia coli in rural household container waters.

Plastic containers in the range of 5-20 L are widely used - especially in rural African settings - to collect, transport and store water for domestic use, including drinking, bathing and hygiene. The pathogen content of the waters in these containers has not been adequately characterized as yet. This paper presents the primary findings of a synoptic survey of drinking water quality samples from these containers and involved collection of bacterial indicator and pathogenicity gene data. In total, 571 samples of a variety of waters were taken in rural communities in South Africa and the Escherichia coli numbers measured. Of the E. coli positive samples, 46% (n = 148) were screened for the presence of E. coli pathogen gene markers. Though synoptic, the survey provided many insights into the issues that drove the study. Container use markedly degraded water quality as judged by indicator counts, even where improved water supply services were in place. Household container use also appeared to promote regrowth or contamination of containers with pathogenic E. coli strains. Polymerase chain reaction (PCR) analysis also showed that the diversity of potential pathogenic E. coli carrying virulence genes was great. All seven genes screened for (Ial, Stx1, Stx2, EaeA, Eagg, ST, LT) were found in the waters, alone or as mixtures (number of different combinations = 31) including those characteristic of the more dangerous invasive and haemorrhagic E. coli strains. Given the central role of containers in the management of water supply to rural communities, it is clear the microbiology of these waters requires much further characterization.

Estimating the risk from sewage treatment plant effluent in the Sydney catchment area.

This study employed Quantitative Microbial Risk Assessment (QMRA) to estimate the gastrointestinal risks associated with Cryptosporidium and Giardia discharged from three STPs located within the Lake Burragorang catchment. The QMRA considered baseline and various hazardous event scenarios (e.g. plant failure and heavy rainfall). Under baseline conditions, the combined effect of constructed barriers, catchment barriers and dilution reduced pathogen numbers from the discharge of all three STPs by 10 to 14 orders of magnitude. This was sufficient for the risk to be well below currently mooted benchmarks of 'tolerable risk', even when relatively conservative assumptions were applied. For all hazardous event scenarios, the level of risk remained low, which illustrated the benefit of multiple barriers. Provisionally it appears that the STPs currently discharging into the waterways of the catchment do not pose an unacceptable or unmanageable risk to Sydney's drinking water consumers.

Solar radiation disinfection of drinking water at temperate latitudes: inactivation rates for an optimised reactor configuration.

Solar radiation-driven inactivation of bacteria, virus and protozoan pathogen models was quantified in simulated drinking water at a temperate latitude (34 degrees S). The water was seeded with Enterococcus faecalis, Clostridium sporogenes spores, and P22 bacteriophage, each at ca 1x10(5) mL(-1), and exposed to natural sunlight in 30-L reaction vessels. Water temperature ranged from 17 to 39 degrees C during the experiments lasting up to 6h. Dark controls showed little inactivation and so it was concluded that the inactivation observed was primarily driven by non-thermal processes. The optimised reactor design achieved S90 values (cumulative exposure required for 90% reduction) for the test microorganisms in the range 0.63-1.82 MJ m(-2) of Global Solar Exposure (GSX) without the need for TiO2 as a catalyst. High turbidity (840-920 NTU) only reduced the S(90) value by <40%. Further, when all S90 means were compared this decrease was not statistically significant (prob.>0.05). However, inactivation was significantly reduced for E. faecalis and P22 when the transmittance of UV wavelengths was attenuated by water with high colour (140 PtCo units) or a suboptimally transparent reactor lid (prob.<0.05). S90 values were consistent with those measured by other researchers (ca 1-10 MJ m(-2)) for a range of waters and microorganisms. Although temperatures required for SODIS type pasteurization were not produced, non-thermal inactivation alone appeared to offer a viable means for reliably disinfecting low colour source waters by greater than 4 orders of magnitude on sunny days at 34 degrees S latitude.

Chemical contaminants in feedlot wastes: concentrations, effects and attenuation.

Commercial feedlots for beef cattle finishing are potential sources of a range of trace chemicals which have human health or environmental significance. To ensure adequate protection of human and environmental health from exposure to these chemicals, the application of effective manure and effluent management practices is warranted. The Australian meat and livestock industry has adopted a proactive approach to the identification of best management practices. Accordingly, this review was undertaken to identify key chemical species that may require consideration in the development of guidelines for feedlot manure and effluent management practices in Australia. Important classes of trace chemicals identified include steroidal hormones, antibiotics, ectoparasiticides, mycotoxins, heavy metals and dioxins. These are described in terms of their likely sources, expected concentrations and public health or environmental significance based on international data and research. Androgenic hormones such as testosterone and trenbolone are significantly active in feedlot wastes, but they are poorly understood in terms of fate and environmental implications. The careful management of residues of antibiotics including virginiamycin, tylosin and oxytetracycline appears prudent in terms of minimising the risk of potential public health impacts from resistant strains of bacteria. Good management of ectoparasiticides including synthetic pyrethroids, macrocyclic lactones, fluazuron, and amitraz is important for the prevention of potential ecological implications, particularly towards dung beetles. Very few of these individual chemical contaminants have been thoroughly investigated in terms of concentrations, effects and attenuation in Australian feedlot wastes.

SCADA data and the quantification of hazardous events for QMRA.

The objective of this study was to assess the use of on-line monitoring to support the QMRA at water treatment plants studied in the EU MicroRisk project. SCADA data were obtained from three Catchment-to-Tap Systems (CTS) along with system descriptions, diary records, grab sample data and deviation reports. Particular attention was paid to estimating hazardous event frequency, duration and magnitude. Using Shewart and CUSUM we identified 'change-points' corresponding to events of between 10 min and >1 month duration in timeseries data. Our analysis confirmed it is possible to quantify hazardous event durations from turbidity, chlorine residual and pH records and distinguish them from non-hazardous variability in the timeseries dataset. The durations of most 'events' were short-term (0.5-2.3 h). These data were combined with QMRA to estimate pathogen infection risk arising from such events as chlorination failure. While analysis of SCADA data alone could identify events provisionally, its interpretation was severely constrained in the absence of diary records and other system information. SCADA data analysis should only complement traditional water sampling, rather than replace it. More work on on-line data management, quality control and interpretation is needed before it can be used routinely for event characterization.

Microbial exposure assessment of an urban recreational lake: a case study of the application of new risk-based guidelines.

New WHO and Australian guidelines promote a risk-management approach for minimising exposure to pathogens in recreational waters. Between 2003 and 2005, they were applied to Lake Parramatta (10 ha, 450 ML), a potential recreation site in Sydney, Australia. A three stage approach was developed involving (1) initial suitability assessment using historic data, (2) revised suitability assessment based on new data and (3) characterisation of hazardous (especially wet weather) events. Contrary to the stage 1 suitability classification, stage 2 baseline data indicated that during dry weather the lake had water quality sufficient for primary contact recreation (95th percentiles for enterococci = 19 MPN/100, n = 50) and the major pathogen source was wildfowl. Guideline principles provided a rationale for collecting microbiological and geographic data needed to understand local cycles of lake contamination/recovery. The concept of hazardous events was particularly useful. Studies of stormwater events led us to identify a transition point (> 10 mm rainfall in 24 h) where human-faecal pathogen risks increased and access needed to be controlled. Together baseline and event data yielded operational tools (i.e. event detection methods, action triggers, auditing criteria, remediation priorities) for minimising bather exposure.

Microbial risk and removal--a utility perspective.

In this paper the results of a sampling programme, undertaken as part of the EU MicroRisk project, are described. This project was undertaken to ascertain the occurrence of pathogens and indicators in the River Thames and their subsequent removal through a treatment works. Appropriate physico-chemical surrogates, as determined by statistical correlation are proposed for the microorganisms identified in the raw water. This study shows that under normal raw water conditions the treatment works is able to remove microbial contamination with a significant margin of safety.

Effluent quality from 200 on-site sewage systems: design values for guidelines.

The quality of effluent from an on-site sewage treatment system is a critical factor in designing the disposal area and, hence, ensuring the sustained performance of the system. Contaminant concentrations in effluent are typically specified in regulatory guidelines or standards; however, the accuracy of these guideline values are brought into question due to the poor performance of septic tanks and the high failure rates of disposal systems reported here and elsewhere. Results from studies of septic tank effluent quality indicated that the effluent is of poorer quality than currently suggested by guidelines. Aerated wastewater treatment systems were found to perform to accreditation guidelines; however, insufficient nutrient data is presently available to assess nutrient loads. It is proposed that the 80th percentile of system performance be adopted as the design value for sizing effluent disposal areas to minimise failure associated with overloading. For septic tanks this equates to 660 mg L(-1) SS, 330 mg L(-1) BOD, 250 mg L(-1) TN and 36 mg L(-1) TP.

Hydrogen sulphide production tests and the detection of groundwater faecal contamination by septic seepage.

The 'H2S test' is being advanced for microbiological water quality testing where conventional coliform based methods are impractical or too expensive. It involves ambient temperature incubation of water samples with nutrient formulated to generate hydrogen sulphide when 'faecal' bacteria are present. Recently a WHO review identified several concerns including the limited number of comparative studies, formulation variability, and false positives and negatives. In response we have compared the H2S test's ability to detect and quantify faecal contamination in an aquifer impacted by septic tank leachfields with measurements obtained concurrently using conventional bacterial indicators, coliphages, faecal sterol biomarkers, Cryptosporidium and Giardia. Like these other analytes, H2S testing detected a contamination gradient ranging from high (septic liquid) to moderate (exfiltration zones), to background (e.g. domestic bores), corresponding to indicator removal + dilution by factors > 10(6). Presence/absence tests could not distinguish between heavily and slightly contaminated waters, whereas multi-tube testing (e.g. 10 x 10 mL arrays) did. It was concluded that while the WHO review concerns are justified, the H2S test performance shows promise in sanitary survey work, can be improved by employing an mpn approach and has potential to aid in the protection of source water and identifying contaminated groundwater.

Quantifying the impact of runoff events on microbiological contaminant concentrations entering surface drinking source waters.

Concentrations of microbiological contaminants in streams increase during rainfall-induced higher flow 'event' periods as compared to 'baseflow' conditions. If the stream feeds a drinking water reservoir, such periods of heightened pathogen loads may pose a challenge to the water treatment plant and subsequently a health concern to water consumers downstream. In order to manage this risk, it is desirable to first quantify the differences in surface water quality between baseflow and event conditions. The Event Mean Concentration (EMC) is a flow-weighted average concentration of a contaminant over the duration of a single event, proposed here as a standard parameter for quantifying the net effect of events on microbial water quality. Application of the EMC concept was assessed using flow and quality data for several events from an urbanised catchment. Expected mean EMCs were significantly larger than expected mean baseflow concentrations (p-value< or =0.012) for three microbial agents - Escherichia coil (13,000 [n = 7] v. 610 [n = 16] mpn/100 ml), Cryptosporidium (234 [n = 6] v. 51 [n = 16] oocysts/10 litres) and Campylobacter (48 [n = 5] v. 2.1 [n = 16] mpn/100ml). These parameter estimates were complemented by estimating data variability and uncertainty in the form of second-order random variables. As such the results are in a format appropriate for potential use as components in probabilistic risk assessments evaluating the effect runoff events have on drinking water quality.

Assessing the health implications of turbidity and suspended particles in protected catchments.

The supply of unfiltered disinfected drinking water from Melbourne's fully protected catchments means that the water-quality managers must ensure that the source water poses no public health risk. High turbidity is currently used as a surrogate of pathogens, and harvesting of water is based on its measurement. The work presented here summarises suspended particle and associated pathogen, microbial indicator and faecal biomarker concentrations collected to (a) quantify turbidity in an Australian water supply system and (b) assess the possibility of increasing water harvesting from selected tributaries. Pathogens and microbial indicators were present in low numbers in these source waters; increased turbidity during storm events was not associated with an increase in pathogen concentration. The results confirmed that protected catchments, along with good management, were effective barriers to pathogen contamination. Aesthetic issues still need to be addressed, but no measurable increase in microbiological risk was associated with storm-generated particles.

Results of a modified left atrial maze procedure as a combined procedure.

Starting in November 1999, we performed a left atrial radiofrequency ablation procedure concomitantly to a variety of cardiac surgical procedures. By January 2001, this ablation procedure had been performed on 100 patients (age 65.7 +/- 10.4 years, 53 % male, 47 % female, left atrium 51.0 +/- 7.5 mm) suffering either from chronic or paroxysmal atrial fibrillation. Primary cardiac pathology was mitral valve disease in most cases (43), aortic valve disease (28) or coronary heart disease (27). After bilateral pulmonary veins isolation, an additional ablation line was directed from the left pulmonary veins to the mitral valve annulus (Thermaline probe, Boston Scientific Corporation, USA). Finally, the left atrial appendage was resected. Surgical success was evaluated in the immediate postoperative course, 3 and 6 months postoperatively (ECG and echocardiography), and every year after that. Operative time was 229.7 +/- 56.5 min, ablation time 18.8 +/- 6.9 min. Follow-up is 95 % complete at the time of writing. Mean follow-up time was 7.3 months, ranging from 3 to 23 months. Success (sinus rhythm and atrial contraction) was proven in 72 out of 90 patients (80.0 %) (75.0 % mitral valve surgery, 84.0 % other cardiac surgery). The reported results support a broad spectrum of indications for this left atrial ablation procedure.

Buffer distances for on-site sewage systems in Sydney's drinking water catchments.

Pathogens and nutrients released from on-site sewage systems represent a risk to surface and ground water quality, particularly where there are sensitive receiving waters such as in drinking water catchments. Buffer zones between on-site systems and waterways are one barrier used to protect water quality. The increased time and distance they provide increases the opportunities for the effluent purification functions of the soil to occur. A risk management model is proposed to assess the efficacy of the buffer zones in Sydney's drinking water catchments. The model is the basis for the development of performance based setback distances for on-site systems from waterways, and incorporates stochastic analysis of pathogen and nutrient transport in the environment and consideration of the effluent quality variability from on-site systems. Catchment-scale integration of contaminant transport is employed to facilitate a risk assessment of on-site systems. The risk management model also allows for the impact of on-site system management and maintenance on catchment water quality to be assessed through scenario building and feedback mechanisms.

Centralised versus decentralised sewage systems: a comparison of pathogen and nutrient loads released into Sydney's drinking water catchments.

Data collected from centralised and decentralised sewage treatment plants throughout Sydney's drinking water catchments was used to calculate the relative catchment loads of Cryptosporidium, enteric viruses, nitrogen and phosphorus for an initial screening assessment. Loads were assessed at median and 90 percentile values for expected and worst-cases scenarios. The expected scenario in the Sydney drinking water catchments is that decentralised systems (servicing 32,800 people) provide similar total loads to centralised systems (serving 70% of the catchment population) for total phosphorus (37,090 kg x y(-1)), Cryptosporidium (10(11) oocysts x y(-1)) and enteric viruses (9.1 x 10(13) y(-1)), but higher loads of total nitrogen (237,610 vs. 136,740 kg x y(-1)). Decentralised systems, however, were predicted to have higher loads in the worst-case scenario with 620,620 kg x y(-1) TN, 82,040 kg x y(-1) TP, 7.3 x 10(13) Cryptosporidium oocysts x y(-1) and 9 x 10(15) enteric viruses per year. Greater load variability was experienced with decentralised systems, which presumably reflects less reliability in their current operation and maintenance. Overall, catchment water quality is therefore not only affected by sewage disposal methods, but also failure issues. Decentralised system disposal to land may afford a degree of mitigation that can be enhanced, if the degree of failure is reduced.

The Ross operation as a combined procedure and in complicated cases--is there an increased risk?

BACKGROUND: In this report we address the question whether the Ross operation can be recommended in combined and complicated cardiac procedures. METHODS: From February 1995 to July 2000, we performed 203 Ross operations, 129 with ideal clinical presentation (group 1: mean age 41 +/- 13 years, male 105). In 74 patients, the clinical presentation was complex (group 2: mean age 35 +/- 17 years, male 57), defined as previous aortic or cardiac operations in 32, active endocarditis in 8 or combined procedures in 40 patients. Follow-up is 95 % complete. RESULTS: Neither early mortality nor thromboembolic events were observed. Complications in group 1 vs. group 2 were prolonged ventilation in 1 vs. 1, pacemaker insertion in 1 vs. 2, minor myocardial infarction in none vs. 2 and postoperative bleeds in 2 vs. 3 patients. In group 1, one patient died of hemoptysis at 25 months, and in group 2 one sudden death occurred at 5 months. In the long term, two patients required reoperation for autograft failure in group 1, and one on group 2. Pulmonary stenosis required surgical treatment in one patient of group 2. Echocardiography revealed physiological gradients across the autograft with no significant regurgitation in either group. CONCLUSION: The Ross operation has excellent mid-term results and is a safe and attractive therapeutic approach, both in combined procedures and complex clinical presentations.