Plastic pollution and human pathogens: Towards a conceptual shift in risk management at bathing water and beach environments.

Emerging evidence indicates that micro- and macro-plastics present in water can support a diverse microbial community, including potential human pathogens (e.g., bacteria, viruses). This interaction raises important concerns surrounding the role and suitability of current bathing water regulations and associated pathogen exposure risk within beach environments. In response to this, we critically evaluated the available evidence on plastic-pathogen interactions and identified major gaps in knowledge. This review highlighted the need for a conceptual shift in risk management at public beaches recognising: (i) interconnected environmental risks, e.g., associations between microbial compliance parameters, potential pathogens and both contemporary and legacy plastic pollution; and (ii) an appreciation of risk of exposure to plastic co-pollutants for both water and waterside users. We present a decision-making framework to identify options to manage plastic-associated pathogen risks alongside short- and longer-term research priorities. This advance will help deliver improvements in managing plastic-associated pathogen risk, acknowledging that human exposure potential is not limited to only those who engage in water-based activity. We argue that adopting these recommendations will help create an integrated approach to managing and reducing human exposure to pathogens at bathing, recreational water and beach environments.

Eliciting expert judgements to underpin our understanding of faecal indicator organism loss from septic tank systems.

Septic tank systems (STS) in rural catchments represent a potential source of microbial pollution to watercourses; however, data concerning the risk of faecal indicator organism (FIO) export from STS to surface waters are scarce. In the absence of empirical data, elicitation of expert judgements can provide an alternative approach to aid understanding of FIO pollution risk from STS. Our study employed a structured elicitation process using the Sheffield Elicitation Framework to obtain expert judgements on the proportion of FIOs likely to be delivered from STS to watercourses, based on 36 scenarios combining: (i) septic tank effluent movement risk, driven by soil hydro-morphological characteristics; (ii) distance of septic tank to watercourse; and (iii) degree of slope. Experts used the tertile method to elicit a range of values representing their beliefs of the proportion of FIOs likely to be delivered to a watercourse for each scenario. The experts judged that 93 % of FIOs would likely be delivered from an STS to a watercourse under the highest risk scenario that combined (i) very high STS effluent movement risk, (ii) STS distance to watercourse <10 m, and (iii) a location on a steep slope with gradient >25 %. Under the lowest risk scenario, the proportion of FIOs reaching a watercourse would likely reduce to 5 %. Expert confidence was high for scenarios that represented extremes of risk, while uncertainty increased for scenarios depicting intermediate risk conditions. The behavioural aggregation process employed to obtain a consensus among the experts proved to be useful for highlighting both areas of strong consensus and high uncertainty. The latter therefore represent priorities for future empirical research to further improve our understanding of potential pollution risk from septic tanks and in turn enable better assessments of potential threats to water quality in rural catchments throughout the world where decentralised wastewater systems are common.

Self-reported benefits and risks of open water swimming to health, wellbeing and the environment: Cross-sectional evidence from a survey of Scottish swimmers.

Engaging with natural environments benefits human health by providing opportunities for social interactions, enhancing mental wellbeing and enabling outdoor spaces for physical exercise. Open water swimming has seen a rapid increase in popularity, partly due to the physical health benefits it can provide but also with the growing interest in (re)connecting with nature for environment-health interactions. Using a national-scale online survey of 717 open water swimmers, the aim of this study was to investigate patterns and trends in the perceived benefits and risks of open water swimming to both public health and the environment; and to understand whether these perceived risks and benefits vary across different typologies of swimmers and open water, or 'blue space', environments. Strong associations were found between the most important self-reported benefit associated with open water swimming and both participant age and the categorisation of their typical swim style. All but one of the age-groups surveyed perceived mental wellbeing benefits to be the most important benefit of open water swimming; whilst those aged over 65 identified physical rather than mental wellbeing benefits to be the most important outcome. Participants who preferred lake swimming reported greater concern regarding possible environmental damage caused by the increasing popularity of open water swimming compared to those engaging in river or sea swimming. However, the majority of participants perceived the risks to the environment from open water swimming to be minimal. Our study adds to the growing evidence that open water swimming is perceived by participants as benefitting their mental and physical wellbeing. Improved understanding of the benefits and risks of engaging with blue spaces used for open water swimming can contribute to co-designed policy development to promote safer, healthier and more sustainable outdoor recreation opportunities associated with this increasingly popular outdoor pursuit.

How do weather conditions and environmental characteristics influence aesthetic preferences of freshwater environments?

Freshwater (inland) blue space environments provide a range of public health benefits to visitors. However, health related exposure outcomes are dynamic and can vary depending on several factors, including the environmental characteristics of freshwater environments and their surroundings. Developing and managing inland blue spaces to promote health and wellbeing therefore requires an understanding of whether specific freshwater attributes, and prevailing weather conditions, enhance or devalue landscape aesthetics. The aim of this study was to utilise a mixed-methods research approach to investigate aesthetic preferences of inland blue spaces. A three-phase data collection method was adopted involving (i) analysis of a national-scale landscape image dataset; in combination with (ii) a national-scale online survey; and (iii) a series of in-person focus groups. We found environmental characteristics associated with the waterbody itself, as well as the characteristics of the nearby green space, to have a significant impact on the overall aesthetic appeal of inland blue spaces. Strong preference was demonstrated for inland blue spaces perceived to be of a high environmental quality and which have a natural, rather than human-modified, appearance. The findings highlight the need to conserve the quality of both the waterbody and waterside environment to encourage frequent recreational use and maintain the beneficial public health outcomes associated with inland blue spaces.

Persistence of E. coli in Streambed Sediment Contaminated with Faeces from Dairy Cows, Geese, and Deer: Legacy Risks to Environment and Health.

Legacy stores of faecal pollution in streambed sediments can result in delayed impacts on environmental quality and human health if resuspended into the overlying water column. Different catchment sources of faecal pollution can contribute to a legacy store of microbial pollutants, with size of stores influenced by microbial die-off and faecal accrual rates in the streambed. The aim of this study was to use a mesocosm experiment to characterise the persistence of E. coli derived from faeces of dairy cows, deer, and geese once introduced to streambed sediment under different temperature regimes. The settling rate of solid constituents of faecal material into streambed sediment once delivered into an aquatic environment was also quantified. The persistence patterns of E. coli in streambed sediment were found to vary as a function of faecal source and temperature; die-off of E. coli in sediment contaminated with goose faeces was more rapid than in sediments contaminated with dairy cow or deer faeces. Goose faeces also recorded a more rapid settling rate of faecal particles through the water column relative to dairy cow and deer faeces, suggesting a more efficient delivery of E. coli to streambed sediments associated with this faecal source. Our findings provide new evidence to improve understanding of the potential longer-term risks to both the environment and public health posed by sediments when contaminated with livestock, wildlife, and wildfowl faeces.

Open defaecation by proxy: Tackling the increase of disposable diapers in waste piles in informal settlements.

Disposable diapers are becoming increasingly popular and present an emerging challenge for global waste management, particularly within LMICs. They offer a cheap and convenient way for caregivers to manage child excreta; however, insufficient understanding of safe disposal methods, combined with limited access to waste management services results in hazardous disposal. Used diapers are being increasingly found dumped in the open environment, including in water bodies and in open fields, leading to faecal contamination of the environment and an enhanced risk of transmission of faecal-oral diseases such as cholera and typhoid. United Nations SDG 6 aims to end open defaecation globally by 2030; however, improper disposal of used diapers will hamper progress towards reaching this goal. In this review, we identify current trends in use and subsequent disposal of single use disposable diapers in LMICs, and critically discuss the environmental and public health impacts of current practices, and potential solutions to address these challenges. Contemporary methods for managing the disposal of single use diapers for communities in LMICs tend to be cost prohibitive with few alternative options other than dumping in the environment. Modern cloth diapers offer a low waste alternative to disposable diapers but often carry an unaffordable high upfront cost. Here, in addition to advocating improved efforts by governments to upgrade access and quality of waste management services, we recommend the design and implementation of intervention schemes aimed to increase awareness of safe and hygienic disposal practices for disposable diapers.

Clinically important E. coli strains can persist, and retain their pathogenicity, on environmental plastic and fabric waste.

Plastic waste is ubiquitous in the environment and there are increasing reports of such waste being colonised by human pathogens. However, the ability of pathogens to persist on plastics for long periods, and the risk that they pose to human health, is unknown. Here, under simulated environmental conditions, we aimed to determine if pathogenic bacteria can retain their virulence following a prolonged period on plastic. Using antibiotic selection and luciferase expression for quantification, we show that clinically important strains of E. coli can survive on plastic for at least 28-days. Importantly, these pathogens also retained their virulence (determined by using a Galleria mellonella model as a surrogate for human infection) and in some cases, had enhanced virulence following their recovery from the plastisphere. This indicates that plastics in the environment can act as reservoirs for human pathogens and could facilitate their persistence for extended periods of time. Most importantly human pathogens in the plastisphere are capable of retaining their pathogenicity. Pathogens colonising environmental plastic waste therefore pose a heightened public health risk, particularly in areas where people are exposed to pollution.

Source availability and hydrological connectivity determined nitrate-discharge relationships during rainfall events in karst catchment as revealed by high-frequency nitrate sensing.

Karst terrain seasonal monsoonal rainfall is often associated with high concentrations of nitrate-N in streams draining agricultural land. Such high concentrations can pose problems for environmental and human health. However, the relationship between rainfall events that mobilize nitrate and resulting nitrate export remains poorly understood in karst terrain. To better understand the processes that drive nitrate dynamics during rainfall events, the characteristics of individual rainfall events were analyzed using sensor technology. Thirty-eight rainfall events were separated from the high-frequency dataset spanning 19 months at a karst spring site. The results revealed that nitrate-discharge (N-Q) hysteresis in 79% of rainfall events showed anticlockwise hysteresis loop patterns, indicating nitrate export from long distances within short event periods. Karstic hydrological connectivity and source availability were considered two major determining factors of N-Q hysteresis. Gradual increase in hydrological connectivity during intensive rainfall period accelerated nitrate transportation by karst aquifer systems. Four principal components (PCs, including antecedent conditions PC1&3 and rainfall characteristics PC2&4 explained 82% of the cumulative variance contribution to the rainfall events. Multiple linear regression of four PCs explained more than 50% of the variation of nitrate loading and amplitude during rainfall events, but poorly described nitrate concentrations and hydro-chemistry parameters, which may be influenced by other factors, e.g., nitrate transformation, fertilization time and water-rock interaction. Although variation of N concentration during event flow is evident, accounting for antecedent conditions and rainfall factors can help to predict rainfall event N loading during rainfall events. Pollution of the karstic catchment occurred by a flush of nitrate input following rainfall events; antecedent and rainfall conditions are therefore important factors to consider for the water quality management. Reducing source availability during the wet season may facilitate to reduction of nitrogen loading in similar karst areas.

From wastewater discharge to the beach: Survival of human pathogens bound to microplastics during transfer through the freshwater-marine continuum.

Large quantities of microplastics are regularly discharged from wastewater treatment plants (WWTPs) into the aquatic environment. Once released, these plastics can rapidly become colonised by microbial biofilm, forming distinct plastisphere communities which may include potential pathogens. We hypothesised that the protective environment afforded by the plastisphere would facilitate the survival of potential pathogens during transitions between downstream environmental matrices and thus increase persistence and the potential for environmental dissemination of pathogens. The survival of Escherichia coli, Enterococcus faecalis and Pseudomonas aeruginosa colonising polyethylene or glass particles has been quantified in mesocosm incubation experiments designed to simulate, (1) the direct release of microplastics from WWTPs into freshwater and seawater environments; and (2) the movement of microplastics downstream following discharge from the WWTP through the river-estuary-marine-beach continuum. Culturable E. coli, E. faecalis and P. aeruginosa were successfully able to survive and persist on particles whether they remained in one environmental matrix or transitioned between different environmental matrices. All three bacteria were still detectable on both microplastic and glass particles after 25 days, with higher concentrations on microplastic compared to glass particles; however, there were no differences in bacterial die-off rates between the two materials. This potential for environmental survival of pathogens in the plastisphere could facilitate their transition into places where human exposure is greater (e.g., bathing waters and beach environments). Therefore, risks associated with pathogen-microplastic co-pollutants in the environment, emphasises the urgency for updated regulations on wastewater discharge and the management of microplastic generation and release.

Time since faecal deposition influences mobilisation of culturable E. coli and intestinal enterococci from deer, goose and dairy cow faeces.

Mobilisation is a term used to describe the supply of a pollutant from its environmental source, e.g., soil or faeces, into a hydrological transfer pathway. The overarching aim of this study was to determine, using a laboratory-based approach, whether faecal indicator bacteria (FIB) are hydrologically mobilised in different quantities from a typical agricultural, wildlife and wildfowl source, namely dairy cattle, red deer and greylag goose faeces. The mobilisation of FIB from fresh and ageing faeces under two contrasting temperatures was determined, with significant differences in the concentrations of both E. coli and intestinal enterococci lost from all faecal sources. FIB mobilisation from these faecal matrices followed the order of dairy cow > goose > deer (greatest to least, expressed as a proportion of the total FIB present). Significant changes in mobilisation rates from faecal sources over time were also recorded and this was influenced by the temperature at which the faecal material had aged over the course of the 12-day study. Characterising how indicators of waterborne pathogens are mobilised in the environment is of fundamental importance to inform models and risk assessments and develop effective strategies for reducing microbial pollution in catchment drainage waters and associated downstream impacts. Our findings add quantitative evidence to support the understanding of FIB mobilisation potential from three important faecal sources in the environment.

Decoding river pollution trends and their landscape determinants in an ecologically fragile karst basin using a machine learning model.

Karst watersheds accommodate high landscape complexity and are influenced by both human-induced and natural activity, which affects the formation and process of runoff, sediment connectivity and contaminant transport and alters natural hydrological and nutrient cycling. However, physical monitoring stations are costly and labor-intensive, which has confined the assessment of water quality impairments on spatial scale. The geographical characteristics of catchments are potential influencing factors of water quality, often overlooked in previous studies of highly heterogeneous karst landscape. To solve this problem, we developed a machining learning method and applied Extreme Gradient Boosting (XGBoost) to predict the spatial distribution of water quality in the world's most ecologically fragile karst watershed. We used the Shapley Addition interpretation (SHAP) to explain the potential determinants. Before this process, we first used the water quality damage index (WQI-DET) to evaluate the water quality impairment status and determined that CODMn, TN and TP were causing river water quality impairments in the WRB. Second, we selected 46 watershed features based on the three key processes (sources-mobilization-transport) which affect the temporal and spatial variation of river pollutants to predict water quality in unmonitored reaches and decipher the potential determinants of river impairments. The predicting range of CODMn spanned from 1.39 mg/L to 17.40 mg/L. The predictions of TP and TN ranged from 0.02 to 1.31 mg/L and 0.25-5.72 mg/L, respectively. In general, the XGBoost model performs well in predicting the concentration of water quality in the WRB. SHAP explained that pollutant levels may be driven by three factors: anthropogenic sources (agricultural pollution inputs), fragile soils (low organic carbon content and high soil permeability to water flow), and pollutant transport mechanisms (TWI, carbonate rocks). Our study provides key data to support decision-making for water quality restoration projects in the WRB and information to help bridge the science:policy gap.

Binding, recovery, and infectiousness of enveloped and non-enveloped viruses associated with plastic pollution in surface water.

Microplastics in wastewater and surface water rapidly become colonised by microbial biofilm. Such 'plastisphere' communities are hypothesised to persist longer and be disseminated further in the environment and may act as a vector for human pathogens, particularly as microplastics entering wastewater treatment plants are exposed to high concentrations of pathogenic bacteria. However, the potential for human viral pathogens to become associated with the plastisphere has never before been quantified. Here, we have used rotavirus (RV) SA11 (a non-enveloped enteric virus) and the enveloped bacteriophage Phi6 as model viruses to quantify binding and recovery from biofilm-colonised microplastic pellets in three different water treatments (filtered and non-filtered surface water, and surface water with added nutrients). Viruses associated with biofilm-colonised pellets were more stable compared to those remaining in the water. While infectious particles and genome copies of RV remained stable over the 48 h sampling period, Phi6 stability was highly impacted, with a reduction ranging from 2.18 to 3.94 log10. Virus particles were protected against inactivation factors when associated with the biofilm on microplastic surfaces, and when there was a high concentration of particulate matter in the liquid phase. Although our results suggest that the presence of an envelope may limit virus interaction with the plastisphere, the ability to recover both enveloped and non-enveloped infectious viruses from colonised microplastic pellets highlights an additional potential public health risk of surface waters becoming contaminated with microplastics, and subsequent human exposure to microplastics in the environment.

Sewage-associated plastic waste washed up on beaches can act as a reservoir for faecal bacteria, potential human pathogens, and genes for antimicrobial resistance.

Sewage-associated plastic wastes, such as wet wipes and cotton bud sticks, commonly wash up on beaches; however, it is unclear whether this represents a public health risk. In this study, sewage-associated plastic waste, and naturally occurring substrates (seaweed and sand), were collected from ten beaches along the Firth of Forth estuary (Scotland, UK) and analysed using selective media for the faecal indicator organisms (FIOs) E. coli and intestinal enterococci (IE), and potential human pathogens (Vibrio spp.). Minimum inhibitory concentration (MIC) analysis was used to determine antibiotic resistance in selected strains. FIOs and Vibrio were more often associated with wet wipes and cotton bud sticks than with seaweed, and there was evidence of resistance to several antibiotics. This work demonstrates that plastics associated with sewage pollution can facilitate the survival and dissemination of FIOs and Vibrio and thus, could present an as yet unquantified potential risk to human health at the beach.

Quantifying the importance of plastic pollution for the dissemination of human pathogens: The challenges of choosing an appropriate 'control' material.

Discarded plastic wastes in the environment are serious challenges for sustainable waste management and for the delivery of environmental and public health. Plastics in the environment become rapidly colonised by microbial biofilm, and importantly this so-called 'plastisphere' can also support, or even enrich human pathogens. The plastisphere provides a protective environment and could facilitate the increased survival, transport and dissemination of human pathogens and thus increase the likelihood of pathogens coming into contact with humans, e.g., through direct exposure at beaches or bathing waters. However, much of our understanding about the relative risks associated with human pathogens colonising environmental plastic pollution has been inferred from taxonomic identification of pathogens in the plastisphere, or laboratory experiments on the relative behaviour of plastics colonised by human pathogens. There is, therefore, a pressing need to understand whether plastics play a greater role in promoting the survival and dispersal of human pathogens within the environment compared to other substrates (either natural materials or other pollutants). In this paper, we consider all published studies that have detected human pathogenic bacteria on the surfaces of environmental plastic pollution and critically discuss the challenges of selecting an appropriate control material for plastisphere experiments. Whilst it is clear there is no 'perfect' control material for all plastisphere studies, understanding the context-specific role plastics play compared to other substrates for transferring human pathogens through the environment is important for quantifying the potential risk that colonised plastic pollution may have for environmental and public health.

Bathing Water Quality Monitoring Practices in Europe and the United States.

Many countries including EU Member States (EUMS) and the United States (U.S.) regularly monitor the microbial quality of bathing water to protect public health. This study comprehensively evaluates the EU bathing water directive (BWD) and the U.S. recreational water quality criteria (RWQC) as regulatory frameworks for monitoring microbial quality of bathing water. The major differences between these two regulatory frameworks are the provision of bathing water profiles, classification of bathing sites based on the pollution level, variations in the sampling frequency, accepted probable illness risk, epidemiological studies conducted during the development of guideline values, and monitoring methods. There are also similarities between the two approaches given that both enumerate viable fecal indicator bacteria (FIB) as an index of the potential risk to human health in bathing water and accept such risk up to a certain level. However, enumeration of FIB using methods outlined within these current regulatory frameworks does not consider the source of contamination nor variation in inactivation rates of enteric microbes in different ecological contexts, which is dependent on factors such as temperature, solar radiation, and salinity in various climatic regions within their geographical areas. A comprehensive "tool-box approach", i.e., coupling of FIB and viral pathogen indicators with microbial source tracking for regulatory purposes, offers potential for delivering improved understanding to better protect the health of bathers.

Survival of human enteric and respiratory viruses on plastics in soil, freshwater, and marine environments.

The public health significance of plastics and microplastics in different environmental matrices has mainly focused on the toxicological effects of human ingestion. But these pollutants can also harbour pathogenic bacteria as the surfaces of plastics in the environment quickly become colonised by microbial biofilm. This novel microbial habitat has been termed the 'plastisphere' and could facilitate the survival and dissemination of important bacterial and fungal pathogens. Importantly, however, the role of plastic pollution as a secondary pathway for the transmission of human pathogenic viruses has never been addressed. Due to the high prevalence of both enteric and respiratory viruses in the population and in the environment, there is significant potential for human viruses to become associated with the plastisphere. In this review we critically evaluate current knowledge on the interaction of human enteric and respiratory viruses with plastic surfaces and identify the main environmental conditions and plastic characteristics that could affect virus survival and persistence in the environment. Our hypothesis is that the plastisphere can enhance the adhesion, survival and dissemination of human pathogenic viruses and potentially lead to more effective transfer and transmission of viral diseases within the environment. We identify key research questions needed to more fully assess the potential human health risks associated with viruses on plastic surfaces. These include understanding, (1) the mechanisms of viral attachment to either naked or biofilm-colonised plastic (2) how the structural characteristics of viruses (e.g., enveloped, or non-enveloped), affect their persistence in the plastisphere, (3) whether the plastisphere offers protection and increases the persistence of infectious viruses in soil, freshwater, and marine environments.

Rainfall and conduit drainage combine to accelerate nitrate loss from a karst agroecosystem: Insights from stable isotope tracing and high-frequency nitrate sensing.

Understanding where nitrate is mobilized from and under what conditions is required to reduce nitrate loss and protect water quality. Low frequency sampling may inadequately capture hydrological and biogeochemical processes that will influence nitrate behavior. We used high-frequency isotope sampling and in-situ nitrate sensing to explore nitrate export and transformation in a karst critical zone. Nitrate was mobilised during light rainfall, and transferred from soil layers to the karst matrix, where some nitrate was retained and denitrified. Nitrate isotopic composition changed rapidly during the rising limb of events and slowly during the falling limb. The main nitrate source was synthetic fertiliser (up to 80% during event flow), transported by conduit flow following high rainfall events, and this contribution increased significantly as discharge increased. Soil organic nitrogen contribution remained constant indicating at baseflow this is the primary source. Isotope source appointment of nitrate export revealed that synthetic fertilizer accounted for more than half of the total nitrate export, which is double that of the secondary source (soil organic nitrogen), providing valuable information to inform catchment management to reduce nitrate losses and fluvial loading. Careful land management and fertilizer use are necessary to avoid nitrate pollution in the karst agroecosystem, for example by timing fertilizer applications to allow for plant uptake of nitrate before rainfall can flush it from the soils into the karst and ultimately into catchment drainage.

Impact of Freeze-Thaw Cycles on Die-Off of E. coli and Intestinal Enterococci in Deer and Dairy Faeces: Implications for Landscape Contamination of Watercourses.

Characterising faecal indicator organism (FIO) survival in the environment is important for informing land management and minimising public health risk to downstream water users. However, key gaps in knowledge include understanding how wildlife contribute to catchment-wide FIO sources and how FIO survival is affected by low environmental temperatures. The aim of this study was to quantify E. coli and intestinal enterococci die-off in dairy cow versus red deer faecal sources exposed to repeated freeze-thaw cycles under controlled laboratory conditions. Survival of FIOs in water exposed to freeze-thaw was also investigated to help interpret survival responses. Both E. coli and intestinal enterococci were capable of surviving sub-freezing conditions with the faeces from both animals able to sustain relatively high FIO concentrations, as indicated by modelling, and observations revealing persistence in excess of 11 days and in some cases confirmed beyond 22 days. Die-off responses of deer-derived FIOs in both faeces and water exposed to low temperatures provide much needed information to enable better accounting of the varied catchment sources of faecal pollution and results from this study help constrain the parameterisation of die-off coefficients to better inform more integrated modelling and decision-making for microbial water quality management.

Freshwater blue space and population health: An emerging research agenda.

Growing evidence suggests that access and exposure to water bodies or blue spaces can provide a variety of health and well-being benefits. Attempts to quantify these 'blue-health' benefits have largely focused on coastal environments, with freshwater blue spaces receiving far less attention despite over 50% of the global population living within 3 km of a body of freshwater and populations living in landlocked areas having limited coastal access. This critical review identifies opportunities to improve our understanding of the relationship between freshwater blue space and health and well-being and outlines key recommendations to broaden the portfolio of emerging research needs associated with the field of blue-health. Recognising fundamental distinctions in relationships between health outcomes and access and exposure to freshwater versus coastal blue space is critical and further research is required to determine the mechanisms that link exposure to freshwater blue space with tangible health outcomes and to understand how such mechanisms vary across a range of freshwater environments. Furthermore, methodological improvements are necessary as spatial approaches adopted to quantify access and exposure to freshwater blue space often fail to account for the unique physical characteristics of freshwater and come with a variety of limitations. Based on the findings of this review, a suite of research needs are proposed, which can be categorised into three broad themes: (i) establishing a freshwater blue-health methodological framework; (ii) advancing the empirical freshwater blue-health evidence base; and (iii) promoting freshwater blue-health opportunities. When taken together, these research themes offer opportunities to advance current understanding and better integrate freshwater blue space into the wider nature-health research agenda.

Chronic urban hotspots and agricultural drainage drive microbial pollution of karst water resources in rural developing regions.

Contamination of surface and groundwater systems with human and animal faecal matter leads to exposure of reliant populations to disease causing micro-organisms. This exposure route remains a major cause of infection and mortality in developing countries, particularly rural regions. To meet the UN's sustainable development goal 6: Ensure availability and sustainable management of water and sanitation for all, we need to identify the key controls on faecal contamination across relevant settings. We conducted a high-resolution spatial study of E. coli concentration in catchment drainage waters over 6 months in a mixed land-use catchment in the extensive karst region extending across impoverished southwest China. Using a mixed effects modelling framework, we tested how land-use, karst hydrology, antecedent meteorological conditions, agricultural cycles, hydrochemistry, and position in the catchment system affected E. coli concentrations. Land-use was the best predictor of faecal contamination levels. Sites in urban areas were chronically highly contaminated, but water draining from agricultural land was also consistently contaminated and there was a catchment wide pulse of higher E. coli concentrations, turbidity, and discharge during paddy field drainage. E. coli concentration increased with increasing antecedent rainfall across all land-use types and compartments of the karst hydrological system (underground and surface waters), but decreased with increasing pH. This is interpreted to be a result of processes affecting pH, such as water residence time, rather than the direct effect of pH on E. coli survival. Improved containment and treatment of human waste in areas of higher population density would likely reduce contamination hotspots, and further research is needed to identify the nature and distribution of sources in agricultural land.