Risk of infectious gastroenteritis in young children living in Québec rural areas with intensive animal farming: results of a case-control study (2004-2007).

This study was designed to evaluate the epidemiology of severe gastroenteritis in children living in Québec rural areas with intensive livestock activities. From September 2005 through June 2007, 165 cases of gastroenteritis in children aged from 6 months to 5 years, hospitalized or notified to the public health department were enrolled, and 326 eligible controls participated. The parents of cases and controls were asked questions about different gastroenteritis risk factors. The quality of the drinking water used by the participants was investigated for microbial indicators as well as for four zoonotic bacterial pathogens (Campylobacter spp, Escherichia coli, Salmonella spp and Yersinia spp) and two enteric parasites (Cryptosporidium spp and Giardia spp). From 134 stool specimen analysed, viruses were detected in 82 cases (61%), while 28 (21%) were found with at least one of the bacteria investigated, and five cases were infected by parasites. Campylobacteriosis was the main bacterial infection (n = 15), followed by Salmonella sp (n = 7) and E. coli O157:H7 (n = 5) among cases with bacterial gastroenteritis. No significant difference was found between cases and controls regarding the quality of water consumed; the frequency of faecal contamination of private wells was also similar between cases and controls. Considering the total cases (including those with a virus), no link was found between severe gastroenteritis and either being in contact with animals or living in a municipality with the highest animal density (4th quartile). However, when considering only cases with a bacterial or parasite infection (n = 32), there was a weak association with pig density that was not statistically significant after adjusting for potential confounders. Contact with domestic, zoo or farm animals were the only environmental factor associated with the disease.

Occurrence of waterborne pathogens and Escherichia coli at offshore drinking water intakes in lake Ontario.

The occurrence of waterborne pathogens was investigated at three drinking water intakes located about 2 km offshore in Lake Ontario. Water sampling was conducted over 3 years for Campylobacter spp., Cryptosporidium spp., Giardia spp., cultivable enteric viruses, and water quality parameters. All pathogens were detected in the offshore source water for each water treatment plant (WTP1 to WTP3), although at relatively low frequencies and concentrations. Giardia was the most common pathogen, occurring in 36% of water samples from the influent of WTP1 (n = 46), and with a maximum concentration of 0.70 cysts/liter in this influent. Cryptosporidium occurred as frequently as 15% in the WTP2 influent (n = 35), with a maximum concentration of 0.40 oocysts/liter in the WTP1 influent. The human Bacteroidales HF183 DNA marker was most common in the WTP1 influent (19%), and this was the only WTP where the Cryptosporidium hominis genotype was detected. No water quality parameter was predictive of pathogen occurrence across all three WTP influents. Escherichia coli was often below detection when pathogens were detected, and spikes in E. coli concentrations often did not coincide with pathogen occurrence. After summer rain events, river plumes had E. coli concentrations as high as 222 CFU/100 ml in surface waters 2 km offshore, without impacting drinking water intakes below the thermocline on the lake bottom. At times, prechlorination to control mussels at offshore intake cribs compromised the use of E. coli for "raw" water quality assessment, particularly for chlorine-resistant Cryptosporidium. E. coli measured by standard methods did not reliably predict pathogen occurrence at drinking water intakes in offshore ecosystems.

Association between potential zoonotic enteric infections in children and environmental risk factors in Quebec, 1999-2006.

This study was designed to evaluate the association of potential zoonotic gastroenteritis in children, and specifically giardiasis, salmonellosis and campylobacteriosis, with environmental risk factors in rural areas of Quebec. Notified cases of gastroenteritis in children of 0-4 years of age reported in the period of 1999 through 2006 from municipalities in southern Quebec with <100,000 inhabitants were investigated. Negative binomial regression models accounting for overdispersion and adjusted for clustering were used to estimate relative risks (RR) associated with livestock densities and drinking water quality. Analyses revealed that, during this period, 2500 cases of gastroenteritis were reported in children of 0-4 years, including 819 cases of giardiasis, 690 of salmonellosis and 852 of campylobacteriosis. The incidence rate associated with all potential zoonotic agents reported was 163 cases/100,000 children-years and this was statistically associated with cattle density: RR Quartile 4/Quartile 1 (Q4/Q1) = 1.92, 95% CI = 1.43-2.58. When estimated specifically for each pathogen, incidence rates of giardiasis (RR Q4/Q1 = 1.79, 95% CI = 1.11-2.87), salmonellosis (RR Q4/Q1 = 1.64, 95% CI = 1.15-2.33) and campylobacteriosis (RR Q4/Q1 = 2.43, 95% CI = 1.60-3.68) were also associated with cattle density, with a monotonic increase of RR with increasing animal density. Giardiasis incidence was also positively associated with a poor drinking water quality, although no statistically significant association was found. Our results suggest that, in rural Quebec, bacterial and parasitic enteric infections in young children may be zoonoses related to environmental risk factors and especially cattle production.

Optimization of microbial DNA extraction and purification from raw wastewater samples for downstream pathogen detection by microarrays.

Numerous waterborne pathogens are difficult to detect and enumerate with accuracy due to methodological limitations and high costs of direct culturing. The purity of DNA extracted from wastewater samples is an important issue in the sensitivity and the usefulness of molecular methods such as polymerase chain reaction (PCR) and hybridizations on DNA microarrays. Ten different DNA extraction procedures, including physical and chemical extraction and purification steps, were examined to ascertain their relative effectiveness for extracting bacterial DNA from wastewater samples. The quality of the differentially extracted DNAs was subsequently assessed by PCR amplification and microarray hybridization. Our results showed that great differences existed among the ten procedures and only a few of the methods gave satisfactory results when applied to bacterial pathogens. This observation suggested that the extraction method needed to be carefully selected to produce significant and confident results in the detection of pathogens from environmental samples.

A fatal waterborne disease epidemic in Walkerton, Ontario: comparison with other waterborne outbreaks in the developed world.

An estimated 2,300 people became seriously ill and seven died from exposure to microbially contaminated drinking water in the town of Walkerton, Ontario, Canada in May 2000. The severity of this drinking water disaster resulted in the Government of Ontario calling a public inquiry by Mr. Justice Dennis O'Connor to address the cause of the outbreak, the role (if any) of government policies in contributing to this outbreak and, ultimately, the implications of this experience on the safety of drinking water across the Province of Ontario. The circumstances surrounding the Walkerton tragedy are an important reference source for those concerned with providing safe drinking water. Although some circumstances are obviously specific to this epidemic, others are uncomfortably reminiscent of waterborne outbreaks that have occurred elsewhere. These recurring themes suggested the need for attention to broad issues of drinking water security and they present the challenge for how drinking water safety can be managed to prevent such tragedies in the future.

Comparison of methods to analyse imprecise faecal coliform count data from environmental samples.

Imprecise values arise when bacterial colonies are too numerous to be counted or when no colonies grow at a specific dilution. Our objective was to show the usefulness of multiple imputation in analysing data containing imprecise values. We also indicate that interval censored regression, which is faster computationally in situations where it applies, can be used, providing similar estimates to imputation. We used bacteriological data from a large epidemiological study in daycare centres to illustrate this method and compared it to a standard method which uses single exact values for the imprecise data. The data consisted of numbers of FC on children's and educators' hands, from sandboxes and from playareas. In general, we found that multiple imputation and interval censored regression provided more conservative intervals than the standard method. The discrepancy in the results highlights both the importance of using a method that best captures the uncertainty in the data and how different conclusions might be drawn. This can be crucial for both researchers and those who are involved in formulating and regulating standards for bacteriological contamination.

Removal of indicator bacteria, human enteric viruses, Giardia cysts, and Cryptosporidium oocysts at a large wastewater primary treatment facility.

Pathogens and fecal indicator bacteria occurrence and removal were studied for a period of 6 months at the Montreal Urban Community wastewater treatment facility. With a capacity of about 7.6 million cubic metres per day (two billion U.S. gallons per day), it is the largest primary physico-chemical treatment plant in America. The plant discharges a nondisinfected effluent containing about 20 mg/L of suspended matter and 0.5 mg/L of total phosphorus on the basis of average annual concentrations. BDO5 (annual mean) is 75 mg/L before treatment and 32 mg/L after treatment. Samples were collected for a period of 6 months, and they demonstrated that the plant was not efficient at removing indicator bacteria and the pathogens tested. Fecal coliforms were the most numerous of the indicator bacteria and their removal averaged 25%. Fecal streptococci removal was 29%, while Escherichia coli removal was 12%. In untreated sewage, fecal coliforms, E. coli, and human enteric viruses were more numerous in summer and early autumn. Fecal streptococci counts remained relatively similar throughout the period. Clostridium perfringens removal averaged 51%. Giardia cysts levels were not markedly different throughout the study period, and 76% of the cysts were removed by treatment. Cryptosporidium oocyst counts were erratic, probably due to the methods, and removal was 27%. Human enteric viruses were detected in all samples of raw and treated wastewater with no removal observed (0%). Overall, the plant did not perform well for the removal of fecal indicator bacteria, human enteric viruses, or parasite cysts. Supplementary treatment and disinfection were recommended to protect public health. Various alternatives are being evaluated.

Occurrence of pathogenic microorganisms in the Saint Lawrence River (Canada) and comparison of health risks for populations using it as their source of drinking water.

A 300-km portion of the Saint Lawrence hydrological basin in the province of Québec (Canada) and 45 water treatment plants were studied. River water used by drinking water treatment plants was analyzed (6-L sample volumes) to determine the level of occurrence of bacterial indicators (total coliforms, fecal coliforms, and Clostridium perfringens) and pathogens (Giardia lamblia, Cryptosporidium, human enteric viruses). Pathogens and bacterial indicators were found at all sites at a wide range of values. Logistic regression analysis revealed significant correlations between the bacterial indicators and the pathogens. Physicochemical and treatment practices data were collected from most water treatment plants and used to estimate the level of removal of pathogens achieved under cold (0 degree C-4 degrees C) and warm (20 degrees C-25 degrees C) water temperature conditions. The calculated removal values were then used to estimate the annual risk of Giardia infection using mathematical models and to compare the sites. The estimated range of probability of infection ranged from 0.75 to less than 0.0001 for the populations exposed. Given the numerous assumptions made, the model probably overestimated the annual risk, but it provided comparative data of the efficacy of the water treatment plants and thereby contributes to the protection of public health.

Poor efficacy of residual chlorine disinfectant in drinking water to inactivate waterborne pathogens in distribution systems.

To evaluate the inactivating power of residual chlorine in a distribution system, test microorganisms (Escherichia coli, Clostridium perfringens, bacteriophage phi-X 170, and poliovirus type 1) were added to drinking water samples obtained from two water treatment plants and their distribution system. Except for Escherichia coli, microorganisms remained relatively unaffected in water from the distribution systems tested. When sewage was added to the water samples, indigenous thermotolerant coliforms were inactivated only when water was obtained from sites very close to the treatment plant and containing a high residual chlorine concentration. Clostridium perfringens was barely inactivated, suggesting that the most resistant pathogens such as Giardia lamblia, Cryptosporidium parvum, and human enteric viruses would not be inactivated. Our results suggest that the maintenance of a free residual concentration in a distribution system does not provide a significant inactivation of pathogens, could even mask events of contamination of the distribution, and thus would provide only a false sense of safety with little active protection of public health. Recent epidemiological studies that have suggested a significant waterborne level of endemic gastrointestinal illness could then be explained by undetected intrusions in the distribution system, intrusions resulting in the infection of a small number of individuals without eliciting an outbreak situation.

Effectiveness of a training program in reducing infections in toddlers attending day care centers.

The objective of this study was to assess the effectiveness of a hygiene program in reducing the incidence of respiratory and diarrheal diseases in toddlers attending day care centers. A randomized field trial was conducted in 52 day care centers in Quebec, Canada, between September 1, 1996 and November 30, 1997. Absences for any reasons and the daily occurrence of colds and/or diarrhea in toddlers were recorded on calendars by the educators. The number of fecal coliforms on children's hands and on educators' hands was measured during three unannounced visits. Overall, 1,729 children were followed in 47 day care centers for a total of 153,643 child-days. The incidence rate of diarrhea was considerably reduced by the effect of monitoring (IRR = 0.73, 95% CI = 0.54,0.97), and the intervention reduced the incidence rate of upper respiratory tract infections (IRR = 0.80, 95% CI = 0.68,0.93). Monitoring alone also had an important effect in reducing the level of bacterial contamination on children's and educators' hands. The results indicate that both an intervention program and monitoring alone play a role in reducing infections in children attending day care centers.

Prevalence of antibodies to the Hawaii strain of human calicivirus as measured by a recombinant protein based immunoassay.

The evaluation of an enzyme immunoassay using recombinant Hawaii virus-like particles (rHV-LPs) with a panel of sera which had been screened previously for antibodies to Norwalk virus (NV) and Mexico virus (MxV) is described. The assay was also applied to study the epidemiology of Hawaii virus. Adult volunteers challenged with the prototype (genogroup II, human calicivirus) HV developed significant IgG responses (16-32 fold rises) following challenge whereas adults challenged or naturally infected with NV (genogroup I) did not. Lesser antibody responses (4-8 fold rises) were demonstrated in volunteers challenged with Snow Mountain agent (SMA) and patients infected by SRSV 'UK3' and 'UK4' strains, indicating a degree of antigenic relatedness among viruses within genogroup II. Comparison of the seroprevalence of IgG antibodies to rHV, rMxV and rNV in 338 children in London showed that infections with genogroup II viruses are prevalent and occur earlier in life than NV. Many young children had antibodies to MxV but not HV indicating that genogroup II viruses have both conserved and antigenically distinct epitopes. A serological study on 566 Canadians aged between 9 and 79 years showed that the prevalence of antibodies to rHV rose with age from 65-100% and from 53-100% for NV. Measurement of antibody response in a heart transplant patient infected with an MxV-like virus showed significant responses to both rMxV and rHV. Continuous monitoring of the patient over two years showed that antibody levels declined rapidly to prechallenge levels after a year.

Biofilms, infectious agents, and dental unit waterlines: a review.

Aquatic biofilms, which are widespread not only in nature but also in medical and dental devices, can be the source of serious nosocomial infections. In these hardy microbial communities, pathogens like nontuberculous mycobacteria, Pseudomonas aeruginosa, Legionella pneumophila, and other bacteria not only survive but proliferate and lie in wait for susceptible hosts. Not only are these organisms intrinsically resistant to high temperatures and biocides, but the biofilms they inhabit enhance their resistance. This should be of concern to infection control practitioners. The bacterial colonization of dental unit waterlines can be used as a model to investigate the problem of waterborne biofilms in health care settings.

Comparison of methods of sampling for Toxocara species and fecal coliforms in an outdoor day care environment.

OBJECTIVE: To compare three sampling methods and to pretest methods for the determination of fecal coliform (FC) counts and Toxocara species from sand in the day care outdoor environment. DESIGN: The sand samples were obtained from the play area and the sandbox of a day care centre and examined for the presence of FC and Toxocara species, the common roundworm of dogs and cats. The sampling methods included random selection and two types of judgement methods. The latter included one method where domestic animals were judged to be likely to defecate and the other where children would be likely to be playing. In addition, to obtain a global estimate of contamination, the entire areas of both the sandbox and the play area were sampled on the last day. SETTING: Outdoor day care environment. MAIN RESULTS: The most representative levels of bacterial contamination and Toxocara species originated from the combined sample of the entire surface areas rather than from any separate random or judgement method of sampling. FCs were found in all sampled areas of the sandbox (median 910 FCs/g of sand) and of the play area (median 350 FCs/g of sand). Toxocara species were recovered from a number of areas in both the sandbox and the play area. CONCLUSIONS: Research on environmental microbial contamination of outdoor day care settings would benefit from the application of standardized and validated sampling and laboratory methods.

Sources of variation in isolation rate of Giardia lamblia cysts and their homogeneous distribution in river water entering a water treatment plant.

The objective of this work was to determine if differences in the number of Giardia cysts measured in river water were due to the method itself, the analyst, or real differences in the distribution of these cysts in water. To minimize the methodological differences, centrifugation only was used as the primary concentration method. Differences were observed between results from different analysts and they were identified as technical errors. Once the method had been well established, cysts were found to be distributed homogeneously in the river water tested. Small differences were observed among samples collected sequentially at the same time, as well as for samples collected on different days or at different times on the same day. The differences reported in the literature in the number of Giardia cysts detected in water samples from the same site could be an artifact of the methods more than true differences in the counts.

Incidence of Norwalk virus infections during a prospective epidemiological study of drinking water-related gastrointestinal illness.

To determine the seroprevalence of Norwalk virus and whether Norwalk virus contributed to an observed increase in illness in tap water drinkers participating in a prospective epidemiological study, sera collected during the study were examined for changes in Norwalk virus antibody titer, using a specific enzyme immunoassay. Antibodies to Norwalk virus were measured in sera collected in March, June and September 1988 and in June 1989, and antibodies were found in 79% of the individuals. Seroprevalence increased with age, being 55% (ages 9-19), 79% (20-39), 87% (40-49), 84% (50-59), and 100% (60 and older). Norwalk infections occurred in 33% of the individuals during the course of the study. The highest rate of infection (expressed as a monthly rate) was observed during the summer of 1988. These results confirm that a large number of infections owing to Norwalk viruses occur throughout the year. A previous seroconversion or a high serum titer were not always protective. Finally, there was no detectable difference in infection rate between consumers of tap water and consumers of water treated by reverse-osmosis units, suggesting that Norwalk virus infections were not responsible for the excess of gastrointestinal illness observed in tap water drinkers during this epidemiological study.

Blood agar to detect virulence factors in tap water heterotrophic bacteria.

Cytolytic colonies were found in 57% of tap water samples, and up to 6% of samples were found to contain bacteria having three or more virulence factors. The factors evaluated were cytotoxicity, hemolysis, cell adherence, and cell invasiveness. Overall, 17% of the samples contained cytolytic colonies that were adherent and hemolytic. Among the media tested, tryptic soy agar with sheep blood (incubated at 35 degrees C for 48 h) was the best medium for the detection of cytolytic colonies. Of the colonies growing on this medium, 13% were cytolytic, whereas on medium R2A, less than 3% were cytolytic. Furthermore, when tryptic soy agar with blood was used, 24% of the samples contained colonies with at least three virulence factors whereas only 5% were positive with R2A. Routine monitoring by using tryptic soy agar with sheep blood is suggested as an appropriate procedure for the detection of bacteria with pathogenic potential in drinking water.

Clostridium perfringens and somatic coliphages as indicators of the efficiency of drinking water treatment for viruses and protozoan cysts.

To find the most suitable indicator of viral and parasitic contamination of drinking water, large-volume samples were collected and analyzed for the presence of pathogens (cultivable human enteric viruses, Giardia lamblia cysts, and Cryptosporidium oocysts) and potential indicators (somatic and male-specific coliphages, Clostridium perfringens). The samples were obtained from three water treatment plants by using conventional or better treatments (ozonation, biological filtration). All samples of river water contained the microorganisms sought, and only C. perfringens counts were correlated with human enteric viruses, cysts, or oocysts. For settled and filtered water samples, all indicators were statistically correlated with human enteric viruses but not with cysts or oocysts. By using multiple regression, the somatic coliphage counts were the only explanatory variable for the human enteric virus counts in settled water, while in filtered water samples it was C. perfringens counts. Finished water samples of 1,000 liters each were free of all microorganisms, except for a single sample that contained low levels of cysts and oocysts of undetermined viability. Three of nine finished water samples of 20,000 liters each revealed residual levels of somatic coliphages at 0.03, 0.10, and 0.26 per 100 liters. Measured virus removal was more than 4 to 5 log10, and cyst removal was more than 4 log10. Coliphage and C. perfringens counts suggested that the total removal and inactivation was more than 7 log10 viable microorganisms. C. perfringens counts appear to be the most suitable indicator for the inactivation and removal of viruses in drinking water treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

A randomized trial to evaluate the risk of gastrointestinal disease due to consumption of drinking water meeting current microbiological standards.

BACKGROUND: This project directly and empirically measured the level of gastrointestinal (GI) illness related to the consumption of tapwater prepared from sewage-contaminated surface waters and meeting current water quality criteria. METHODS: A randomized intervention trial was carried out; 299 eligible households were supplied with domestic water filters (reverse-osmosis) that eliminate microbial and chemical contaminants from their water, and 307 households were left with their usual tapwater without a filter. The GI symptomatology was evaluated by means of a family health diary maintained prospectively by all study families over a 15-month period. RESULTS: The estimated annual incidence of GI illness was 0.76 among tapwater drinkers compared with 0.50 among filtered water drinkers (p less than 0.01). These findings were consistently observed in all population subgroups. CONCLUSION: It is estimated that 35% of the reported GI illnesses among the tapwater drinkers were water-related and preventable. Our results raise questions about the adequacy of current standards of drinking water quality to prevent water-borne endemic gastrointestinal illness.

Gastrointestinal health effects associated with the consumption of drinking water produced by point-of-use domestic reverse-osmosis filtration units.

During a prospective epidemiological study of gastrointestinal health effects associated with the consumption of drinking water produced by reverse-osmosis domestic units, a correlation was demonstrated between the bacterial counts on R2A medium incubated at 35 degrees C and the reported gastrointestinal symptoms in families who used these units. A univariate correlation was found with bacterial counts on R2A medium at 20 degrees C but was confounded by the bacterial counts at 35 degrees C. Other variables, such as family size and amount of water consumed, were not independently explanatory of the rate of illness. These observations raise concerns for the possibility of increased disease associated with certain point-of-use treatment devices for domestic use when high levels of bacterial growth occur.