Experiences of the SARS-CoV-2 pandemic amongst Australian healthcare workers: from stressors to protective factors.

BACKGROUND: The SARS-CoV-2 pandemic has critically challenged healthcare systems globally. Examining the experiences of healthcare workers (HCWs) is important for optimizing ongoing and future pandemic responses. OBJECTIVES: In-depth exploration of Australian HCWs' experiences of the SARS-CoV-2 pandemic, with a focus on reported stressors vis-à-vis protective factors. METHODS: Individual interviews were performed with 63 HCWs in Australia. A range of professional streams and operational staff were included. Thematic analysis was performed. RESULTS: Thematic analysis identified stressors centred on paucity of, or changing, evidence, leading to absence of, or mistrust in, guidelines; unprecedented alterations to the autonomy and sense of control of clinicians; and deficiencies in communication and support. Key protective factors included: the development of clear guidance from respected clinical leaders or recognized clinical bodies, interpersonal support, and strong teamwork, leadership, and a sense of organizational preparedness. CONCLUSIONS: This study provides insights into the key organizational sources of emotional stress for HCWs within pandemic responses and describes experiences of protective factors. HCWs experiencing unprecedented uncertainty, fear, and rapid change, rely on clear communication, strong leadership, guidelines endorsed by recognized expert groups or individuals, and have increased reliance on interpersonal support. Structured strategies for leadership and communication at team, service group and organizational levels, provision of psychological support, and consideration of the potential negative effects of centralizing control, would assist in ameliorating the extreme pressures of working within a pandemic environment.

Microbial water pollution: a screening tool for initial catchment-scale assessment and source apportionment.

The European Union Water Framework Directive requires that Management Plans are developed for individual River Basin Districts. From the point of view of faecal indicator organisms (FIOs), there is a critical need for screening tools that can provide a rapid assessment of the likely FIO concentrations and fluxes within catchments under base- and high-flow conditions, and of the balance ('source apportionment') between agriculture- and sewage-derived sources. Accordingly, the present paper reports on: (1) the development of preliminary generic models, using water quality and land cover data from previous UK catchment studies for assessing FIO concentrations, fluxes and source apportionment within catchments during the summer bathing season; (2) the calibration of national land use data, against data previously used in the models; and (3) provisional FIO concentration and source-apportionment assessments for England and Wales. The models clearly highlighted the crucial importance of high-flow conditions for the flux of FIOs within catchments. At high flow, improved grassland (and associated livestock) was the key FIO source; FIO loadings derived from catchments with high proportions of improved grassland were shown to be as high as from urbanized catchments; and in many rural catchments, especially in NW and SW England and Wales, which are important areas of lowland livestock (especially dairy) farming, ≥ 40% of FIOs was assessed to be derived from agricultural sources. In contrast, under base-flow conditions, when there was little or no runoff from agricultural land, urban (i.e. sewerage-related) sources were assessed to dominate, and even in rural areas the majority of FIOs were attributed to urban sources. The results of the study demonstrate the potential of this type of approach, particularly in light of climate change and the likelihood of more high-flow events, in underpinning informed policy development and prioritization of investment.

Faecal indicator organism concentrations and catchment export coefficients in the UK.

Characterisation of faecal indicator organism (FIO) concentrations and export coefficients for catchments with particular combinations of land use and under specific climatic regimes is critical in developing models to predict daily loads and apportion sources of the microbial parameters used to regulate water quality. Accordingly, this paper presents a synthesis of FIO concentration and export coefficient data for the summer bathing season, with some comparative winter data, for 205 river/stream sampling points widely distributed across mainland UK. In terms of both geometric mean (GM) FIO concentrations and export coefficients (expressed as cfu km(-2) h(-1)), the results reveal (1) statistically significant elevations at high flow compared with base flow, with concentrations typically increasing by more than an order of magnitude and export coefficients by about two orders; (2) significantly higher values in summer than in winter under high-flow conditions; and (3) extremely wide variability between the catchments (e.g. four orders of magnitude range for GM faecal coliform concentrations), which closely reflects land use-with urban areas and improved pastures identified as key FIO sources. Generally, these two most polluting land uses are concentrated in lowland areas where runoff (m3 km(-2) h(-1)) is low compared with upland areas, which in the UK are dominated by rough grazing and forestry. Consequently, contrasts in export coefficients between land use types are less than for FIO concentrations. The GMs reported for most land use categories are based on 13 sites and exhibit quite narrow confidence intervals. They may therefore be applied with some confidence to other catchments in the UK and similar geographical regions elsewhere. Examples are presented to illustrate how the results can be used to estimate daily summer base- and high-flow FIO loads for catchments with different land use types, and to assess the likely effectiveness of certain strategies for reducing FIO pollutant loadings in areas with extensive areas of lowland improved pasture.

Farmyards, an overlooked source for highly contaminated runoff.

Summer sampling of storm runoff generated from areas of roofs and hardstanding situated on four dairy/beef farms has provided novel information regarding its microbiological and chemical quality. All farm hardstandings generated runoff that was contaminated with respect to those pollutants (faecal coliforms, FC, and faecal streptococci, FS, major nutrients, organic carbon) that are ubiquitously associated with faecal matter and urine. The separate analysis of roof runoff indicated that these can contribute significant concentrations of FS, phosphorus (P) and potentially toxic elements such as zinc (Zn), and suggests a level of 'background' contamination originating from wash-off of bird droppings and in the case of Zn galvanised surfaces. On average hardstanding runoff showed enhanced concentrations of >4 orders of magnitude for FC and 2-3 for major nutrients and carbon relative to roof runoff. Organic forms of nitrogen (N) and P contributed significantly (averaging >40%) to the total dissolved fraction in both roof and hardstanding runoff. Part of the substantial variability in composition of runoff samples could be attributed to differences between farms as well as the timing of sample collection during individual storms. Where situations allowed, a comparison of water upstream and downstream of the farmyard demonstrated they acted as a source of multiple contaminants not only during hydrologically active storm events but also during dry periods. Contamination pathways included a combination of both point (e.g., septic overflows) and non-point (e.g., seepage from livestock housing) sources. Farmyards situated within intensive livestock farming areas such as SW Scotland, would be expected to have significant local and accumulated downstream impacts on the aquatic environment. Localised impacts would be particularly important for headwaters and low order streams.

Quantitative catchment profiling to apportion faecal indicator organism budgets for the Ribble system, the UK's sentinel drainage basin for Water Framework Directive research.

Under the EU Water Framework Directive (WFD) 20/60/EC and the US Federal Water Pollution Control Act 2002 management of water quality within river drainage basins has shifted from traditional point-source control to a holistic approach whereby the overall contribution of point and diffuse sources of pollutants has to be considered. Consequently, there is a requirement to undertake source-apportionment studies of pollutant fluxes within catchments. The inclusion of the Bathing Water Directive (BWD), under the list of 'protected areas' in the WFD places a requirement to control sources of faecal indicator organisms within catchments in order to achieve the objectives of both the BWD (and its revision - 2006/7/EC) and the WFD. This study was therefore initiated to quantify catchment-derived fluxes of faecal indicator compliance parameters originating from both point and diffuse sources. The Ribble drainage basin is the single UK sentinel WFD research catchment and discharges to the south of the Fylde coast, which includes a number of high profile, historically non-compliant, bathing waters. Faecal indicator concentrations (faecal coliform concentrations are reported herein) were measured at 41 riverine locations, the 15 largest wastewater treatment works (WwTWs) and 15 combined sewer overflows (CSOs) across the Ribble basin over a 44-day period during the 2002 bathing season. The sampling programme included targeting rainfall-induced high flow events and sample results were categorised as either base flow or high flow. At the riverine sites, geometric mean faecal coliform concentrations showed statistically significant elevation at high flow compared to base flow. The resultant faecal coliform flux estimates revealed that over 90% of the total organism load to the Ribble Estuary was discharged by sewage related sources during high flow events. These sewage sources were largely related to the urban areas to the south and east of the Ribble basin, with over half the load associated with the relatively small subcatchment of the River Douglas. The majority of this load was attributed to two WwTWs that discharge through a common outfall close to the tidal limit of this catchment. Budgets adjusted to accommodate the impact of proposed UV disinfection of these effluents showed that the load from these sources would be reduced significantly during base flow conditions. However, during high flow events loads would still remain high due to the operation of storm sewage overflows from stormwater retention tanks. The study identified untreated storm sewage spills from urban infrastructure and WwTW stormwater retention tanks as the dominant component of the high flow flux of faecal indicators to receiving waters of the Fylde coast and the associated bathing waters.

Faecal indicator organism concentrations in sewage and treated effluents.

The importance of faecal indicator organism (FIO) fluxes within drainage basins is increasing as the European Union (EU) Water Framework Directive and the United States Clean Water Act place requirements on regulators to manage point and diffuse sources of microbial pollution causing non-compliance (EU) or impairment (US) of receiving waters. Central to this management task is knowledge of the likely FIO concentrations in raw sewage and treated effluents, but few empirical data have been published in the peer-reviewed literature. Accordingly, this paper presents results for 1933 samples from 162 different sewage discharge sites in the UK and Jersey, which encompass 12 types of sewage-related discharge, representative of untreated sewage and primary-, secondary- and tertiary-treated effluents. Geometric means (GMs) and 95% confidence intervals (CIs) have been used to characterise base- and high-flow FIO concentrations. The data sets and sub-sets are mostly quite large (n 40) and may therefore be applied with some confidence to comparable discharge sites in similar geographical regions. Very marked, statistically significant reductions in GM FIO concentrations result from secondary and tertiary treatment, and there are statistically significant differences between some secondary and some tertiary treatments. Flow conditions are also shown to be important: untreated sewage and effluent from primary treatment plant have lower concentrations at high flow, due to dilution within combined sewerage systems, whereas some treated effluents (e.g. from activated sludge plant) have higher concentrations at high flow because of the shorter residence time within the plant. Under base-flow conditions, secondary treatments result in estimated GM FIO reductions of 95.22-99.29% (cf. primary-treated effluent). Corresponding figures for tertiary treatment plants (cf. secondary-treated effluent) are 93.24-96.59% for reedbed/grass plots and 99.71-99.92% for UV disinfection. Results suggest that secondary and tertiary treatment plants are less effective under high-flow conditions, but further high-flow sampling is required to confirm this.

The microbiological quality of seven large commercial private water supplies in the United Kingdom.

Some 1% of the UK population derives their potable water from 140,000 private water supplies (PWSs) regulated by Local Authorities. The overwhelming majority of these are very small domestic supplies serving a single property or a small number of properties. Treatment for such supplies is rudimentary or non-existent and their microbiological quality has been shown to be poor in every published study to date. Private water supplies serving commercial enterprises such as hotels, restaurants, food production premises and factories are more frequently treated and subject to closer regulation in the United Kingdom. As a result, it has been assumed that these larger commercial supplies are less likely to experience elevated faecal indicator and pathogen concentrations at the consumer tap which have been observed at small domestic supplies.This paper reports on intensive monitoring at seven commercial private water supplies (six of which were treated) spread throughout the UK serving hotels, holiday parks and food production enterprises. Daily sampling of 'potable' water, both at the consumer tap and using large volume filtration for Giardia and Cryptosporidium spp. was conducted over two six week periods in the spring and autumn of 2000. This allowed the effects of short term episodic peaks in faecal indicator and pathogen concentration to be quantified. All the supplies experienced intermittent pathogen presence and only one, a chlorinated deep borehole supply, fully complied with UK water quality regulations during both periods of sampling.Poor microbiological water quality typically followed periods of heavy rainfall. This suggests that the design and installation of such systems should be undertaken only after the likely range of raw water quality has been characterised, which requires a thorough understanding of the effects of flow and seasonality on raw water quality. There is no reason to suspect that the monitored sites are uncharacteristic of other commercial supplies and the results reinforce public health concerns related to domestic supplies. Furthermore, the pattern of contamination is highly episodic, commonly lasting only a few days. Thus, the relatively infrequent regulatory monitoring of such supplies would be unlikely to identify the poor water quality episodes and does not provide the data necessary for public health protection. Although some statistical relationship was found between faecal indicator organisms and the presence of pathogens, the use of FIOs in assessments of regulatory compliance may not always provide a reliable measure of public health risk, i.e. indicator absence does not preclude pathogen presence. The results of this study suggest that a risk assessment system similar to the WHO 'Water Safety Planning' approach might offer a more appropriate regulatory paradigm for private water supplies.

Reducing fluxes of faecal indicator compliance parameters to bathing waters from diffuse agricultural sources: the Brighouse Bay study, Scotland.

The European Water Framework Directive requires the integrated management of point and diffuse pollution to achieve 'good' water quality in 'protected areas'. These include bathing waters, which are regulated using faecal indicator organisms as compliance parameters. Thus, for the first time, European regulators are faced with the control of faecal indicator fluxes from agricultural sources where these impact on bathing water compliance locations. Concurrently, reforms to the European Union (EU) Common Agricultural Policy offer scope for supporting on-farm measures producing environmental benefits through the new 'single farm payments' and the concept of 'cross-compliance'. This paper reports the first UK study involving remedial measures, principally stream bank fencing, designed to reduce faecal indicator fluxes at the catchment scale. Considerable reduction in faecal indicator flux was observed, but this was insufficient to ensure bathing water compliance with either Directive 76/160/EEC standards or new health-evidence-based criteria proposed by WHO and the European Commission.

Estimation of diffuse and point source microbial pollution in the ribble catchment discharging to bathing waters in the north west of England.

Achieving compliance with the mandatory standards of the 1976 Bathing Water Directive (76/160/EEC) is required at all U.K. identified bathing waters. In recent years, the Fylde coast has been an area of significant investments in 'point source' control, which have not proven, in isolation, to satisfactorily achieve compliance with the mandatory, let alone the guide, levels of water quality in the Directive. The potential impact of riverine sources of pollution was first confirmed after a study in 1997. The completion of sewerage system enhancements offered the potential for the study of faecal indicator delivery from upstream sources comprising both point sources and diffuse agricultural sources. A research project to define these elements commenced in 2001. Initially, a desk study reported here, estimated the principal infrastructure contributions within the Ribble catchment. A second phase of this investigation has involved acquisition of empirical water quality and hydrological data from the catchment during the 2002 bathing season. These data have been used further to calibrate the 'budgets' and 'delivery' modelling and these data are still being analysed. This paper reports the initial desk study approach to faecal indicator budget estimation using available data from the sewerage infrastructure and catchment sources of faecal indicators.

Decay of intestinal enterococci concentrations in high-energy estuarine and coastal waters: towards real-time T90 values for modelling faecal indicators in recreational waters.

Intestinal enterococci are the principal 'health-evidence-based' parameter recommended by WHO for the assessment of marine recreational water compliance. Understanding the survival characteristics of these organisms in nearshore waters is central to public health protection using robust modelling to effect real-time prediction of water quality at recreation sites as recently suggested by WHO and the Commission of the European Communities Previous models have more often focused on the coliform parameters and assumed two static day-time and night-time T90 values to characterise the decay process. The principal driver for enterococci survival is the received dose of irradiance from sunlight. In the water column, transmission of irradiance is determined by turbidity produced by suspended material. This paper reports the results of irradiated microcosm experiments using simulated sunlight to investigate the decay of intestinal enterococci in relatively turbid estuarine and coastal waters collected from the Severn Estuary and Bristol Channel, UK. High-turbidity estuarine waters produced a T90 value of 39.5 h. Low-turbidity coastal waters produced a much shorter T90 value of 6.6 h. In experiments receiving no irradiation, high-turbidity estuarine waters also produced a longer T90 of 65.1 h compared with corresponding low-turbidity coastal waters, T90 24.8 h. Irradiated T90 values were correlated with salinity, turbidity and suspended solids (r>0.8, p<0.001). The results suggest that enterococci decay in irradiated experiments with turbidity >200 NTU is similar to decay observed under dark conditions. Most significantly, these results suggest that modelling turbidity and or suspended solids offers a potential means of predicting T90 values in 'real-time' for discrete cells of a hydrodynamic model.

Modelling faecal indicator concentrations in large rural catchments using land use and topographic data.

AIMS: To characterize and model spatial variations in faecal-indicator organism concentrations in watercourses draining a large rural catchment during the bathing season. METHODS AND RESULTS: Presumptive coliform (PC), presumptive Eschericia coli (PE) and presumptive enterococci (PEnt) concentrations were determined under base- and high-flow conditions at 24 monitoring points in the Rheidol/Ystwyth catchment, Wales. Relationships with land use and topographic variables within their 'subcatchments' were investigated. Geometric mean (GM) concentrations typically increase more than 10-fold at high flow. The proportion of improved pasture within subcatchments explains 81.6, 73.0 and 85.8%, respectively, of the variance in high-flow GM PC, PE and PEnt concentrations. Distributed modelling suggests that organisms derived from more distant parts of subcatchments may be lost through die-off and sedimentation along watercourses at base flow, although not at high flow. Reductions in concentrations are also evident downstream of reservoir impoundments. CONCLUSIONS: Large rural catchments may contribute substantially to faecal indicator loadings in coastal waters. Indicator concentrations can be modelled successfully using land use and topographic data. SIGNIFICANCE AND IMPACT OF THE STUDY: Development of a modelling approach that provides valuable insight into faecal indicator sources and the transport and survival of these organisms within large catchments.

Relationships between microbial water quality and environmental conditions in coastal recreational waters: the Fylde coast, UK.

This paper explores ways in which the analysis of microbial data from routine compliance monitoring, in combination with basic environmental data, can provide insight into the factors affecting faecal-indicator organism concentrations in coastal waters. In the case study presented, eight designated bathing waters on the Fylde coast are continuing to exhibit unreliable compliance with the Imperative standards for total coliform (TC) and faecal coliform (FC) concentrations specified in the EU Bathing Water Directive (76/160/EEC), despite significant reductions in geometric mean concentrations following recent major investment in the sewerage infrastructure. Faecal streptococci (FS) concentrations have remained high and have not been improved by the new sewerage schemes. The results suggest that, prior to the schemes, higher bacterial concentrations were strongly associated with rainfall; and sewage sources were important for TC and FC, but less important for FS, which may have been more strongly affected by diffuse catchment sources. In the post-schemes period, catchment sources appear to be of greater significance; rainfall remains as a significant, though less important, predictor; and tide height at time of sampling, together with variables such as sunshine and the proportion of onshore winds (which affect the survival and movement of bacteria that have already entered the coastal waters), assume greater significance. The approach used here provides a cost-effective management tool for the exploratory investigation of any monitoring point that is failing to meet recreational water quality standards.

Estimates of the severity of illnesses associated with bathing in marine recreational waters contaminated with domestic sewage.

BACKGROUND: During the summers of 1989-1992 we conducted four randomized intervention trials at four separate UK bathing locations judged of acceptable quality under current USEPA and EU criteria. The results showed bathers to be at increased risk of gastroenteritis, acute febrile respiratory illness (ICD-9 461-466, 480), ear and eye infections relative to non-bathers. The public health significance of these findings has been questioned based upon the unproven assumption that these illnesses are minor in nature and thus of questionable public health significance. METHODS: The severity of these illnesses or ailments in terms of duration of illness, percentage of participants seeking medical treatment, and number of days of lost normal daily activity among study participants reporting specific illnesses or ailments were assessed. In addition the attributable proportion of illness among the exposed (bathers) was calculated for each illness or ailment. RESULTS: Average duration of illness ranged from approximately 4 days to approximately 8 days depending on the specific illness reported. The percentage of study participants seeking medical treatment ranged from 4.2% to 22.2% while the percentage reporting the loss of at least one day of normal daily activity ranged from 7.0% to 25.9% depending on the illness reported. The overall percentage of each illness that can be directly attributable to exposure to marine waters contaminated with domestic sewage ranged from a low of 34.5% for gastroenteritis to a high of 65.8% for ear infections. CONCLUSIONS: To our knowledge, this is the first study to assess and report the severity of illnesses associated with bathing in recreational waters contaminated with domestic sewage. Illness associated with bathing in marine waters contaminated with domestic sewage can no longer be viewed as minor, and indeed can have a substantial impact on the public health.

Faecal indicator impacts on recreational waters: budget studies and diffuse source modelling.

A series of investigations are underway which have quantified the contribution of faecal indicators delivered to nearshore coastal waters from the sewerage system and riverine inputs. Studies have been completed in Jersey, Staithes, Yorkshire, South Wales and the North-west. The research protocols have involved quantification of high and low flow faecal indicator delivery from the sewerage system and riverine sources as well as construction of nonpoint source models designed to predict faecal indicator delivery from diffuse, catchment sources. These investigations suggest a dynamic, but predictable, balance between inputs from the sewerage system and from 'catchment' sources. The sewerage system dominates during low flow conditions but is often overtaken by riverine inputs during high flow conditions after rainfall. Many bathing beach locations exhibit non-compliance after rainfall when stream inputs, rather than sewerage inputs, commonly dominate. The implications of this input pattern is that routine monitoring data may not provide information relevant to new infrastructure planning designed to achieve bathing beach compliance. This suggests that the present scientific information base is insufficient to underpin the extensive UK infra-structure investment programmes designed to ensure compliance with existing EU Directive 76/160/EEC standards. Furthermore, results to date, suggest that management attention must expand from its historical focus on infra-structure provision to incorporate diffuse sources of faecal indicator loading which present a new set of management and modelling challenges.

Marine waters contaminated with domestic sewage: nonenteric illnesses associated with bather exposure in the United Kingdom.

OBJECTIVES: This study identified possible dose-response relationships among bathers exposed to marine waters contaminated with domestic sewage and subsequent risk of nonenteric illness. METHODS: Four intervention follow-up studies were conducted within the United Kingdom. Healthy volunteers (n = 1273) were randomized into bather and nonbather groups. Intensive water-quality monitoring was used to assign five bacteriological indices of water quality to individual bathers. Illnesses studied were acute febrile respiratory illness, and eye, ear, and skin ailments. RESULTS: Fecal streptococci exposure was predictive of acute febrile respiratory illness, while fecal coliform exposure was predictive of ear ailments. Estimated thresholds of effect occurred at bather exposures above 60 fecal streptococci and 100 fecal coliform per 100 ml of water, respectively. Although no relationship was found between eye ailments and indicator organism exposure, compared with nonbathers, bathers were at higher risk for eye ailments. CONCLUSIONS: Nonenteric illness can be transmitted via recreational contact with marine waters contaminated with sewage. These results argue against the use of a single indicator to establish water quality standards.

Lying in everyday life.

In 2 diary studies of lying, 77 college students reported telling 2 lies a day, and 70 community members told 1. Participants told more self-centered lies than other-oriented lies, except in dyads involving only women, in which other-oriented lies were as common as self-centered ones. Participants told relatively more self-centered lies to men and relatively more other-oriented lies to women. Consistent with the view of lying as an everyday social interaction process, participants said that they did not regard their lies as serious and did not plan them much or worry about being caught. Still, social interactions in which lies were told were less pleasant and less intimate than those in which no lies were told.

Indicator organism sources and coastal water quality: a catchment study on the island of Jersey.

Compliance monitoring of bathing waters at La Grève de Lecq on the North coast of Jersey revealed a significant deterioration in water quality between 1992 and 1993, as indexed by presumptive coliform, presumptive Escherichia coli and streptococci concentrations. During the 1993 bathing season the beach failed to attain the compliance with the EC Guideline criteria for presumptive E. coli and streptococci. A bacteriological survey of the stream catchment draining to the beach revealed that: (i) concentrations of faecal indicator organisms were enhanced at high discharge after rainfall; and (ii) a captive water fowl population, which expanded between 1990 and 1993, was a potential source of faecal pollution. Strategies for catchment management are discussed.