Legionellosis on the rise: A scoping review of sporadic, community-acquired incidence in the United States.

Over the past two decades, the incidence of legionellosis has been steadily increasing in the United States though there is noclear explanation for the main factors driving the increase. While legionellosis is the leading cause of waterborne outbreaks in the US, most cases are sporadic and acquired in community settings where the environmental source is never identified. This scoping review aimed to summarise the drivers of infections in the USA and determine the magnitude of impact each potential driver may have. A total of 1,738 titles were screened, and 18 articles were identified that met the inclusion criteria. Strong evidence was found for precipitation as a major driver, and both temperature and relative humidity were found to be moderate drivers of incidence. Increased testing and improved diagnostic methods were classified as moderate drivers, and the ageing U.S. population was a minor driver of increasing incidence. Racial and socioeconomic inequities and water and housing infrastructure were found to be potential factors explaining the increasing incidence though they were largely understudied in the context of non-outbreak cases. Understanding the complex relationships between environmental, infrastructure, and population factors driving legionellosis incidence is important to optimise mitigation strategies and public policy.

Minimally Invasive Saliva Testing to Monitor Norovirus Infection in Community Settings.

BACKGROUND: Norovirus is a leading cause of acute gastroenteritis worldwide. Routine norovirus diagnosis requires stool collection. The goal of this study was to develop and validate a noninvasive method to diagnose norovirus to complement stool diagnostics and to facilitate studies on transmission. METHODS: A multiplex immunoassay to measure salivary immunoglobulin G (IgG) responses to 5 common norovirus genotypes (GI.1, GII.2, GII.4, GII.6, and GII.17) was developed. The assay was validated using acute and convalescent saliva samples collected from Peruvian children <5 years of age with polymerase chain reaction (PCR)-diagnosed norovirus infections (n = 175) and controls (n = 32). The assay sensitivity and specificity were calculated to determine infection status based on fold rise of salivary norovirus genotype-specific IgG using norovirus genotype from stool as reference. RESULTS: The salivary assay detected recent norovirus infections and correctly assigned the infecting genotype. Sensitivity was 71% and specificity was 96% across the evaluated genotypes compared to PCR-diagnosed norovirus infection. CONCLUSIONS: This saliva-based assay will be a useful tool to monitor norovirus transmission in high-risk settings such as daycare centers or hospitals. Cross-reactivity is limited between the tested genotypes, which represent the most commonly circulating genotypes.

Women's and girls' experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis.

BACKGROUND: Attention to women's and girls' menstrual needs is critical for global health and gender equality. The importance of this neglected experience has been elucidated by a growing body of qualitative research, which we systematically reviewed and synthesised. METHODS AND FINDINGS: We undertook systematic searching to identify qualitative studies of women's and girls' experiences of menstruation in low- and middle-income countries (LMICs). Of 6,892 citations screened, 76 studies reported in 87 citations were included. Studies captured the experiences of over 6,000 participants from 35 countries. This included 45 studies from sub-Saharan Africa (with the greatest number of studies from Kenya [n = 7], Uganda [n = 6], and Ethiopia [n = 5]), 21 from South Asia (including India [n = 12] and Nepal [n = 5]), 8 from East Asia and the Pacific, 5 from Latin America and the Caribbean, 5 from the Middle East and North Africa, and 1 study from Europe and Central Asia. Through synthesis, we identified overarching themes and their relationships to develop a directional model of menstrual experience. This model maps distal and proximal antecedents of menstrual experience through to the impacts of this experience on health and well-being. The sociocultural context, including menstrual stigma and gender norms, influenced experiences by limiting knowledge about menstruation, limiting social support, and shaping internalised and externally enforced behavioural expectations. Resource limitations underlay inadequate physical infrastructure to support menstruation, as well as an economic environment restricting access to affordable menstrual materials. Menstrual experience included multiple themes: menstrual practices, perceptions of practices and environments, confidence, shame and distress, and containment of bleeding and odour. These components of experience were interlinked and contributed to negative impacts on women's and girls' lives. Impacts included harms to physical and psychological health as well as education and social engagement. Our review is limited by the available studies. Study quality was varied, with 18 studies rated as high, 35 medium, and 23 low trustworthiness. Sampling and analysis tended to be untrustworthy in lower-quality studies. Studies focused on the experiences of adolescent girls were most strongly represented, and we achieved early saturation for this group. Reflecting the focus of menstrual health research globally, there was an absence of studies focused on adult women and those from certain geographical areas. CONCLUSIONS: Through synthesis of extant qualitative studies of menstrual experience, we highlight consistent challenges and developed an integrated model of menstrual experience. This model hypothesises directional pathways that could be tested by future studies and may serve as a framework for program and policy development by highlighting critical antecedents and pathways through which interventions could improve women's and girls' health and well-being. REVIEW PROTOCOL REGISTRATION: The review protocol registration is PROSPERO: CRD42018089581.

Wealthy, urban, educated. Who is represented in population surveys of women's menstrual hygiene management?

Inadequate menstrual hygiene presents a barrier to women's dignity and health. Recent attention to this marginalised challenge has resulted in the first national assessments of menstrual practices. Intuitively, surveys require women to have had a recent menses to be eligible. This study seeks to determine if there are demographic differences between women who are eligible and ineligible to answer questions about their menstrual hygiene during these assessments. Secondary analyses were undertaken on nationally or state representative data collected by the Performance Monitoring and Accountability 2020 survey programme across eight countries (Burkina Faso, Ethiopia, Ghana, India, Kenya, Niger, Nigeria, and Uganda). Female respondents were included in the study and compared on whether they had a menstrual period within the past three months and thus were eligible to answer questions regarding menstrual practices. On average, 29% of surveyed women across samples were ineligible to be asked menstrual hygiene questions. Higher levels of education, wealth, and urban residence were associated with higher odds of eligibility. Young and unmarried women were also more likely to be eligible. Demographic differences between eligible and ineligible women were consistent across all countries. Wealthy, urban, and educated women are more likely to be eligible to answer survey questions about menstrual hygiene. While population surveys may be representative of menstruating women, proportions of menstrual hygiene practices reported underrepresent the experiences of more vulnerable groups. These groups are likely to have greater struggles with menstrual hygiene when they are menstruating.

Infectivity reduction efficacy of UV irradiation and peracetic acid-UV combined treatment on MS2 bacteriophage and murine norovirus in secondary wastewater effluent.

Peracetic acid (PAA) is a strong oxidant/bactericide that has been applied in various industries (e.g., food processing, pharmaceuticals, medical device sterilization, etc.) as a disinfectant. There is increasing interest in using PAA for wastewater disinfection because it does not form halogenated byproducts, and no post-treatment quenching is required. Previous studies have demonstrated good efficiency in controlling bacteria in wastewater, but limited information is available for viruses, especially those hosted by mammals (e.g., norovirus). Therefore, a study on the infectivity reduction of murine norovirus (MNV) was undertaken to evaluate the disinfection efficacy of PAA or UV alone and in combination with UV irradiation in undisinfected secondary effluent from a municipal wastewater reclamation facility (MWW) and phosphate buffer solution (PBS) at pH 7. Experiments employing MS2 bacteriophage were also performed in parallel for comparison purposes. MS2 infectivity reduction was found to be lower than MNV infectivity reduction for each condition studied - PAA, PAA + UV, and UV disinfection. These data suggest that MS2 may not be an appropriate surrogate to accurately predict the reduction of MNV infectivity. UV irradiation, in a dose range of 5-250 mJ/cm2, provided linear log inactivation (-log (N/N0)) with a regression slope (cm2mJ-1) of 0.031-0.034 and 0.165-0.202 for MS2 and MNV, respectively. UV irradiation provided similar inactivation for MS2 and MNV in both suspensions (PBS or MWW). Low infectivity reduction of MS2 was observed when PAA was used alone at a practical dose of 1.5 mg/L and below. A greater reduction of both MNV and MS2 was observed in PAA disinfection experiments using PBS as the microbial suspension medium, than in secondary effluent. Similar results were observed in PAA + UV experiments, in which greater synergistic effects were found in PBS than in MWW. Results of OH radical formation experiments suggest the presence of radical scavengers in MWW, which resulted in less opportunity for MNV and MS2 to encounter OHradicals. This study also demonstrated that the type of water can have a substantial impact on wastewater disinfection when employing PAA or PAA + UV treatment due to the matrix effect and the presence of radical scavengers, respectively. The results from this study could be employed to aid in the conceptual design of PAA and UV disinfection facilities, especially when norovirus is the organism of concern.

Inactivation of Human Norovirus Genogroups I and II and Surrogates by Free Chlorine in Postharvest Leafy Green Wash Water.

Human noroviruses (hNoVs) are a known public health concern associated with the consumption of leafy green vegetables. While a number of studies have investigated pathogen reduction on the surfaces of leafy greens during the postharvest washing process, there remains a paucity of data on the level of treatment needed to inactivate viruses in the wash water, which is critical for preventing cross-contamination. The objective of this study was to quantify the susceptibility of hNoV genotype I (GI), hNoV GII, murine norovirus (MNV), and bacteriophage MS2 to free chlorine in whole leaf, chopped romaine, and shredded iceberg lettuce industrial leafy green wash waters, each sampled three times over a 4-month period. A suite of kinetic inactivation models was fit to the viral reduction data to aid in quantification of concentration-time (CT) values. Results indicate that 3-log10 infectivity reduction was achieved at CT values of less than 0.2 mg · min/liter for MNV and 2.5 mg · min/liter for MS2 in all wash water types. CT values for 2-log10 molecular reduction of hNoV GI in whole leaf and chopped romaine wash waters were 1.5 and 0.9 mg · min/liter, respectively. For hNoV GII, CT values were 13.0 and 7.5 mg · min/liter, respectively. In shredded iceberg wash water, 3-log10 molecular reduction was not observed for any virus over the time course of experiments. These findings demonstrate that noroviruses may exhibit genogroup-dependent resistance to free chlorine and emphasize the importance of distinguishing between genogroups in hNoV persistence studies.IMPORTANCE Postharvest washing of millions of pounds of leafy greens is performed daily in industrial processing facilities with the intention of removing dirt, debris, and pathogenic microorganisms prior to packaging. Modest inactivation of pathogenic microorganisms (less than 2 log10) is known to occur on the surfaces of leafy greens during washing. Therefore, the primary purpose of the sanitizing agent is to maintain microbial quality of postharvest processing water in order to limit cross-contamination. This study modeled viral inactivation data and quantified the free-chlorine CT values that processing facilities must meet in order to achieve the desired level of hNoV GI and GII reduction. Disinfection experiments were conducted in industrial leafy green wash water collected from a full-scale fresh produce processing facility in the United States, and hNoV GI and GII results were compared with surrogate molecular and infectivity data.

Environmental Determinants of Vibrio parahaemolyticus in the Chesapeake Bay.

Vibrio parahaemolyticus naturally occurs in brackish and marine waters and is one of the leading causes of seafood-borne illness. Previous work studying the ecology of V. parahaemolyticus has often been limited in geographic extent and lacked a full range of environmental measures. This study used a unique large data set of surface water samples in the Chesapeake Bay (n = 1,385) collected from 148 monitoring stations from 2007 to 2010. Water was analyzed for more than 20 environmental parameters, with additional meteorological and surrounding land use data. The V. parahaemolyticus-specific genetic markers thermolabile hemolysin (tlh), thermostable direct hemolysin (tdh), and tdh-related hemolysin (trh) were assayed using quantitative PCR (qPCR), and interval-censored regression models with nonlinear effects were estimated to account for limits of detection and quantitation. tlh was detected in 19.6% of water samples; tdh or trh markers were not detected. The results confirmed previously reported positive associations for V. parahaemolyticus abundance with temperature and turbidity and negative associations with high salinity (>10 to 23‰). Furthermore, the salinity relationship was determined to be a function of both low temperature and turbidity, with an increase of either nullifying the high salinity effect. Associations with dissolved oxygen and phosphate also appeared stronger when samples were taken near human developments. A renewed focus on the V. parahaemolyticus ecological paradigm is warranted to protect public health.IMPORTANCE Vibrio parahaemolyticus is one of the leading causes of seafood-borne illness in the United States and across the globe. Exposure is often through consuming raw or undercooked shellfish. Given the natural presence of the bacterium in the marine environment, an improved understanding of its environmental determinants is necessary for future preventative measures. This analysis of environmental Vibrio parahaemolyticus is one of only a few that utilize a large data set measured over a wide geographic and temporal range. The analysis also includes a large number of environmental parameters for Vibrio modeling, many of which have previously only been tested sporadically, and some of which have not been considered before. The results of the analysis revealed previously unknown relationships between salinity, turbidity, and temperature that provide significant insight into the abundance and persistence of V. parahaemolyticus bacterium in the environment. This information will be essential for developing environmental forecast models for the bacterium.

Reduction of Human Norovirus GI, GII, and Surrogates by Peracetic Acid and Monochloramine in Municipal Secondary Wastewater Effluent.

The objective of this study was to characterize human norovirus (hNoV) GI and GII reductions during disinfection by peracetic acid (PAA) and monochloramine in secondary wastewater (WW) and phosphate buffer (PB) as assessed by reverse transcription-qPCR (RT-qPCR). Infectivity and RT-qPCR reductions are also presented for surrogate viruses murine norovirus (MNV) and bacteriophage MS2 under identical experimental conditions to aid in interpretation of hNoV molecular data. In WW, RT-qPCR reductions were less than 0.5 log10 for all viruses at concentration-time (CT) values up to 450 mg-min/L except for hNoV GI, where 1 log10 reduction was observed at CT values of less than 50 mg-min/L for monochloramine and 200 mg-min/L for PAA. In PB, hNoV GI and MNV exhibited comparable resistance to PAA and monochloramine with CT values for 2 log10 RT-qPCR reduction between 300 and 360 mg-min/L. Less than 1 log10 reduction was observed for MS2 and hNoV GII in PB at CT values for both disinfectants up to 450 mg-min/L. Our results indicate that hNoVs exhibit genogroup dependent resistance and that disinfection practices targeting hNoV GII will result in equivalent or greater reductions for hNoV GI. These data provide valuable comparisons between hNoV and surrogate molecular signals that can begin the process of informing regulators and engineers on WW treatment plant design and operational practices necessary to inactivate hNoVs.

Comparative Inactivation of Murine Norovirus and MS2 Bacteriophage by Peracetic Acid and Monochloramine in Municipal Secondary Wastewater Effluent.

Chlorination has long been used for disinfection of municipal wastewater (MWW) effluent while the use peracetic acid (PAA) has been proposed more recently in the United States. Previous work has demonstrated the bactericidal effectiveness of PAA and monochloramine in wastewater, but limited information is available for viruses, especially ones of mammalian origin (e.g., norovirus). Therefore, a comparative assessment was performed of the virucidal efficacy of PAA and monochloramine against murine norovirus (MNV) and MS2 bacteriophage in secondary effluent MWW and phosphate buffer (PB). A suite of inactivation kinetic models was fit to the viral inactivation data. Predicted concentration-time (CT) values for 1-log10 MS2 reduction by PAA and monochloramine in MWW were 1254 and 1228 mg-min/L, respectively. The 1-, 2-, and 3-log10 model predicted CT values for MNV viral reduction in MWW were 32, 47, and 69 mg-min/L for PAA and 6, 13, and 28 mg-min/L for monochloramine, respectively. Wastewater treatment plant disinfection practices informed by MS2 inactivation data will likely be protective for public health but may overestimate CT values for reduction of MNV. Additionally, equivalent CT values in PB resulted in greater viral reduction which indicate that viral inactivation data in laboratory grade water may not be generalizable to MWW applications.

Floors and Toilets: Association of Floors and Sanitation Practices with Fecal Contamination in Peruvian Amazon Peri-Urban Households.

Over two billion people worldwide lack access to an improved sanitation facility that adequately retains or treats feces. This results in the potential for fecal material containing enteric pathogens to contaminate the environment, including household floors. This study aimed to assess how floor type and sanitation practices impacted the concentration of fecal contamination on household floors. We sampled 189 floor surfaces within 63 households in a peri-urban community in Iquitos, Peru. All samples were analyzed for colony forming units (CFUs) of E. coli, and households were evaluated for their water, sanitation, and hygiene characteristics. Results of multivariate linear regression indicated that households with improved sanitation and cement floors in the kitchen area had reduced fecal contamination to those with unimproved sanitation and dirt floors (Beta: -1.18 log10 E. coli CFU/900 cm(2); 95% confidence interval [CI]: -1.77, -0.60). Households that did not versus did share their sanitation facility also had less contaminated kitchen floors (Beta: -0.65 log10 E. coli CFU/900 cm(2); 95% CI: -1.15, -0.16). These findings suggest that the sanitation facilities of a home may impact the microbial load found on floors, contributing to the potential for household floors to serve as an indirect route of fecal pathogen transmission to children.

Using Geographic Information Systems and Spatial Analysis Methods to Assess Household Water Access and Sanitation Coverage in the SHINE Trial.

Access to water and sanitation are important determinants of behavioral responses to hygiene and sanitation interventions. We estimated cluster-specific water access and sanitation coverage to inform a constrained randomization technique in the SHINE trial. Technicians and engineers inspected all public access water sources to ascertain seasonality, function, and geospatial coordinates. Households and water sources were mapped using open-source geospatial software. The distance from each household to the nearest perennial, functional, protected water source was calculated, and for each cluster, the median distance and the proportion of households within <500 m and >1500 m of such a water source. Cluster-specific sanitation coverage was ascertained using a random sample of 13 households per cluster. These parameters were included as covariates in randomization to optimize balance in water and sanitation access across treatment arms at the start of the trial. The observed high variability between clusters in both parameters suggests that constraining on these factors was needed to reduce risk of bias.

Genotypic and phenotypic characterization of Escherichia coli isolates from feces, hands, and soils in rural Bangladesh via the Colilert Quanti-Tray System.

The increased awareness of the role of environmental matrices in enteric disease transmission has resulted in the need for rapid, field-based methods for fecal indicator bacteria and pathogen detection. Evidence of the specificity of ß-glucuronidase-based assays for detection of Escherichia coli from environmental matrices relevant to enteric pathogen transmission in developing countries, such as hands, soils, and surfaces, is limited. In this study, we quantify the false-positive rate of a ß-glucuronidase-based E. coli detection assay (Colilert) for two environmental reservoirs in Bangladeshi households (hands and soils) and three fecal composite sources (cattle, chicken, and humans). We investigate whether or not the isolation source of E. coli influences phenotypic and genotypic characteristics. Phenotypic characteristics include results of biochemical assays provided by the API-20E test; genotypic characteristics include the Clermont phylogroup and the presence of enteric and/or environmental indicator genes sfmH, rfaI, and fucK. Our findings demonstrate no statistically significant difference in the false-positive rate of Colilert for environmental compared to enteric samples. E. coli isolates from all source types are genetically diverse, representing six of the seven phylogroups, and there is no difference in relative frequency of phylogroups between enteric and environmental samples. We conclude that Colilert, and likely other ß-glucuronidase-based assays, is appropriate for detection of E. coli on hands and in soils with low false-positive rates. Furthermore, E. coli isolated from hands and soils in Bangladeshi households are diverse and indistinguishable from cattle, chicken, and human fecal isolates, using traditional biochemical assays and phylogrouping.

Genes Indicative of Zoonotic and Swine Pathogens Are Persistent in Stream Water and Sediment following a Swine Manure Spill.

Manure spills into streams are relatively frequent, but no studies have characterized stream contamination with zoonotic and veterinary pathogens, or fecal chemicals, following a spill. We tested stream water and sediment over 25 days and downstream for 7.6 km for the following: fecal indicator bacteria (FIB), the fecal indicator chemicals cholesterol and coprostanol, 20 genes for zoonotic and swine-specific bacterial pathogens by presence/absence PCR for viable cells, one swine-specific Escherichia coli toxin gene (STII gene) by quantitative PCR (qPCR), and nine human and animal viruses by qPCR or reverse transcription-qPCR. Twelve days postspill, and 4.2 km downstream, water concentrations of FIB, cholesterol, and coprostanol were 1 to 2 orders of magnitude greater than those detected before, or above, the spill, and genes indicating viable zoonotic or swine-infectious Escherichia coli were detected in water or sediment. STII gene levels increased from undetectable before or above the spill to 10(5) copies/100 ml of water 12 days postspill. Thirteen of 14 water (8/9 sediment) samples had viable STII-carrying cells postspill. Eighteen days postspill, porcine adenovirus and teschovirus were detected 5.6 km downstream. FIB concentrations (per gram [wet weight]) in sediment were greater than in water, and sediment was a continuous reservoir of genes and chemicals postspill. Constituent concentrations were much lower, and detections less frequent, in a runoff event (200 days postspill) following manure application, although the swine-associated STII and stx2e genes were detected. Manure spills are an underappreciated pathway for livestock-derived contaminants to enter streams, with persistent environmental outcomes and the potential for human and veterinary health consequences.

Estimates of Nitrogen, Phosphorus, Biochemical Oxygen Demand, and Fecal Coliforms Entering the Environment Due to Inadequate Sanitation Treatment Technologies in 108 Low and Middle Income Countries.

Understanding the excretion and treatment of human waste (feces and urine) in low and middle income countries (LMICs) is necessary to design appropriate waste management strategies. However, excretion and treatment are often difficult to quantify due to decentralization of excreta management. We address this gap by developing a mechanistic, stochastic model to characterize phosphorus, nitrogen, biochemical oxygen demand (BOD), and fecal coliform pollution from human excreta for 108 LMICs. The model estimates excretion and treatment given three scenarios: (1) use of existing sanitation systems, (2) use of World Health Organization-defined "improved sanitation", and (3) use of best available technologies. Our model estimates that more than 10(9) kg/yr each of phosphorus, nitrogen and BOD are produced. Of this, 22(19-27)%, 11(7-15)%, 17(10-23)%, and 35 (23-47)% (mean and 95% range) BOD, nitrogen, phosphorus, and fecal coliforms, respectively, are removed by existing sanitation systems. Our model estimates that upgrading to "improved sanitation" increases mean removal slightly to between 17 and 53%. Under the best available technology scenario, only approximately 60-80% of pollutants are treated. To reduce impact of nutrient and microbial pollution on human and environmental health, improvements in both access to adequate sanitation and sanitation treatment efficiency are needed.

Monitoring iohexol and its transformation products as evidence of reclaimed water irrigation input to contiguous waterbodies.

Irrigation with reclaimed water alleviates water supply shortages, but excess application often results in impairment of contiguous waterbodies. This project investigated the potential use of iohexol, an iodinated contrast media used in medical imaging, together with its bio- and phototransformation products as unique reconnaissance markers of reclaimed water irrigation intrusion at three golf courses within the state of Florida. Inter-facility iohexol concentrations measured in reclaimed waters ranged over ~2 orders of magnitude while observed intra-facility seasonal differences were ≤1 order of magnitude. A ~50 % reduction in iohexol was observed post-disinfection for reclaimed water facilities utilizing UV light while none was observed with use of chlorine. Iohexol biotransformation products were observed to decline or shift to lower molecular weight compounds when exposed to UV light but not during disinfection using chlorine. Iohexol biotransformation products were observed in most of the samples but were more prevalent in samples collected during the dry season. Much fewer iohexol phototransformation products were observed in chlorinated reclaimed water, and they were only observed in UV light irradiated reclaimed water when the pre-disinfectant iohexol concentration was ≥5000 ng/L or from solar exposure of reclaimed water spiked with 10 µM of iohexol. For the Hillsborough golf course overlaying an aquifer, the groundwater did not contain iohexol or phototransformation products but did contain biotransformation products. It is not known if these biotransformation products are from active or historical intrusion. The additional presence of sucralose in the aquifer suggests that intrusion has occurred within the past 3 years. This study demonstrates three crucial points in attempting to utilize iohexol to denote reclaimed water intrusion from irrigation overapplication: (1) interpretable results are obtained when iohexol concentrations in the reclaimed water employed for irrigation are ≥1000 ng/L, with higher concentrations in the range of ≥5000 ng/L better able to meet analytical sensitivity requirements after further dilution or degradation in the environment; (2) it is beneficial to assess iohexol transformation products in tandem with iohexol monitoring to account for environmental transformations of iohexol during storage and transport to the receiving water of concern; and (3) inclusion of monitoring for sucralose, an artificial sweetener ubiquitous in wastewater sources that is comparatively stable in the environment, can aid in interpretating whether reclaimed water intrusion based on identification of iohexol and transformation products in the receiving water is attributable to historic or ongoing irrigation overapplications.

Two-year evaluation of Legionella in an aging residential building: Assessment of multiple potable water remediation approaches.

Legionella is an opportunistic waterborne pathogen that is difficult to eradicate in colonized drinking water pipes. Legionella control is further challenged by aging water infrastructure and lack of evidence-based guidance for building treatment. This study assessed multiple premise water remediation approaches designed to reduce Legionella pneumophila within a residential building located in an aging, urban drinking water system over a two-year period. Samples (n = 745) were collected from hot and cold-water lines and quantified via most probable number culture. Building-level treatment approaches included three single heat shocks, three single chemical shocks, and continuous low-level chemical disinfection in the potable water system. The building was highly colonized with L. pneumophila with 71 % L. pneumophila positivity. Single heat shocks had a statistically significant L. pneumophila reduction one day post treatment but no significant L. pneumophila reduction at one week, two weeks, and four weeks post treatment. The first two chemical shocks resulted in statistically significant L. pneumophila reduction at two days and four weeks post treatment, but there was a significant L. pneumophila increase at four weeks following the third chemical shock. Continuous low-level chemical disinfection resulted in statistically significant L. pneumophila reduction at ten weeks post treatment implementation. This demonstrates that in a building highly colonized with L. pneumophila, sustained remediation is best achieved using continuous low-level chemical treatment.

Effect of an Arsenic Mitigation Program on Arsenic Exposure in American Indian Communities: A Cluster Randomized Controlled Trial of the Community-Led Strong Heart Water Study Program.

BACKGROUND: Chronic arsenic exposure has been associated with an increased risk of cardiovascular disease; diabetes; cancers of the lung, pancreas and prostate; and all-cause mortality in American Indian communities in the Strong Heart Study. OBJECTIVE: The Strong Heart Water Study (SHWS) designed and evaluated a multilevel, community-led arsenic mitigation program to reduce arsenic exposure among private well users in partnership with Northern Great Plains American Indian Nations. METHODS: A cluster randomized controlled trial (cRCT) was conducted to evaluate the effectiveness of the SHWS arsenic mitigation program over a 2-y period on a) urinary arsenic, and b) reported use of arsenic-safe water for drinking and cooking. The cRCT compared the installation of a point-of-use arsenic filter and a mobile Health (mHealth) program (3 phone calls; SHWS mHealth and Filter arm) to a more intensive program, which included this same program plus three home visits (3 phone calls and 3 home visits; SHWS Intensive arm). RESULTS: A 47% reduction in urinary arsenic [geometric mean (GM)=13.2 to 7.0µg/g creatinine] was observed from baseline to the final follow-up when both study arms were combined. By treatment arm, the reduction in urinary arsenic from baseline to the final follow-up visit was 55% in the mHealth and Filter arm (GM=14.6 to 6.55µg/g creatinine) and 30% in the Intensive arm (GM=11.2 to 7.82µg/g creatinine). There was no significant difference in urinary arsenic levels by treatment arm at the final follow-up visit comparing the Intensive vs. mHealth and Filter arms: GM ratio of 1.21 (95% confidence interval: 0.77, 1.90). In both arms combined, exclusive use of arsenic-safe water from baseline to the final follow-up visit significantly increased for water used for cooking (17% to 53%) and drinking (12% to 46%). DISCUSSION: Delivery of the interventions for the community-led SHWS arsenic mitigation program, including the installation of a point-of-use arsenic filter and a mHealth program on the use of arsenic-safe water (calls only, no home visits), resulted in a significant reduction in urinary arsenic and increases in reported use of arsenic-safe water for drinking and cooking during the 2-y study period. These results demonstrate that the installation of an arsenic filter and phone calls from a mHealth program presents a promising approach to reduce water arsenic exposure among private well users. https://doi.org/10.1289/EHP12548.

Toxicity of commercially available engineered nanoparticles to Caco-2 and SW480 human intestinal epithelial cells.

The effects of ingestion of engineered nanoparticles (NPs), especially via drinking water, are unknown. Using NPs spiked into synthetic water and cell culture media, we investigated cell death, oxidative stress, and inflammatory effects of silver (Ag), titanium dioxide (TiO2), and zinc oxide (ZnO) NPs on human intestinal Caco-2 and SW480 cells. ZnO NPs were cytotoxic to both cell lines, while Ag and TiO2 NPs were toxic only at 100 mg/L to Caco-2 and SW480, respectively. ZnO NPs led to significant cell death in synthetic freshwaters with 1 % phosphate-buffered saline in both cell lines, while Ag and TiO2 NPs in buffered water led to cell death in SW480 cells. NP exposures did not yield significant increased reactive oxygen species generation but all NP exposures led to increased IL-8 cytokine generation in both cell lines. These results indicate cell stress and cell death from NP exposures, with a varied response based on NP composition.

The association between menstrual hygiene, workplace sanitation practices and self-reported urogenital symptoms in a cross-sectional survey of women working in Mukono District, Uganda.

BACKGROUND: Women worldwide experience challenges managing their periods. Menstrual and genital hygiene behaviours have been linked to negative health outcomes, including urogenital symptoms and confirmed infections. However, evidence testing this association has been limited and mixed. This study aimed to (1) describe the menstrual care practices and prevalence of self-reported urogenital symptoms among working women in Mukono District, Uganda, and (2) test the associations between menstrual and genital care practices, and urogenital symptoms. METHODOLOGY: We undertook a cross-sectional survey of women aged 18-45 working in markets, schools, and healthcare facilities in Mukono District, with 499 participants who had menstruated in the past two months included in this analysis. We developed an aggregated measure of menstrual material cleanliness, incorporating material type and laundering practices. Associations with urogenital symptoms were tested using the aggregated material cleanliness measure alongside the frequency of changing materials, handwashing before menstrual tasks, and sanitation practices. RESULTS: Among our sample, 41% experienced urogenital symptoms in the past month. Compared to women exclusively using disposable pads, using appropriately cleaned or non-reused improvised materials (PR = 1.33, 95%CI 1.04-1.71), or inadequately cleaned materials (improvised or commercially produced reusable pads) (PR = 1.84, 95%CI 1.46-3.42) was associated with an increased prevalence of self-reported urogenital symptoms in the last month. There was no difference between those using disposable pads and those using clean reusable pads (PR = 0.98; 95%CI 0.66-1.57). Infrequent handwashing before changing materials (PR 1.18, 95%CI: 0.96-1.47), and delaying urination at work (PR = 1.37, 95%CI: 1.08-1.73) were associated with an increased prevalence of self-reported symptoms. CONCLUSION: Prevalence of self-reported urogenital symptoms was associated with the type and cleanliness of menstrual material used as well as infrequent handwashing and urinary restriction. There is a need for interventions to enable women to maintain cleanliness of their menstrual materials and meet their menstruation, urination and hand washing needs at home and work.

Two-Year Evaluation of Legionella in an Aging Residential Building: Assessment of Multiple Potable Water Remediation Approaches.

Legionella is an opportunistic waterborne pathogen that is difficult to eradicate in colonized drinking water pipes. Legionella control is further challenged by aging water infrastructure and lack of evidence-based guidance for building treatment. This study assessed multiple premise water remediation approaches designed to reduce Legionella pneumophila (Lp) within a residential building located in an aging, urban drinking water system over a two-year period. Samples (n=745) were collected from hot and cold-water lines and quantified via most probable number culture. Building-level treatment approaches included three single heat shocks (HS), three single chemical shocks (CS), and continuous low-level chemical disinfection (CCD) in the potable water system. The building was highly colonized with Lp with 71% Lp positivity. Single HS had a statistically significant Lp reduction one day post treatment but no significant Lp reduction one, two, and four weeks post treatment. The first two CS resulted in statistically significant Lp reduction at two days and four weeks post treatment, but there was a significant Lp increase at four weeks following the third CS. CCD resulted in statistically significant Lp reduction ten weeks post treatment implementation. This demonstrates that in a building highly colonized with Lp, sustained remediation is best achieved using CCD.