A One Water Approach to Address Emerging Challenges and Reduce Waterborne Disease. Michael J. Beach, PhD Centers for Disease Control and Prevention

Transcription

1 A One Water Approach to Address Emerging Challenges and Reduce Waterborne Disease Michael J. Beach, PhD Centers for Disease Control and Prevention Tennessee Public Health Association Southern Health Association Nashville, TN September 16, 2010 National Center for Emerging and Zoonotic Infectious Diseases Division of Foodborne, Waterborne, and Environmental Diseases BACKGROUND

2 Background Leading Causes of Death Globally, Ischemic heart disease (7.2 million) 2. Cancer (7.1 million) 3. Cerebrovascular disease (5.5 million) 4. Lower respiratory infection (3.9 million) 5. Unintentional injuries (3.5 million) 6. HIV/AIDS (2.9 million) 7. COPD (2.7 million) 8. Diarrheal Diseases: Unsafe water, sanitation, hygiene (1.7 million) 9. TB (1.6 million) 10. Intentional injuries (suicide, homicide, war) (1.6 million) 11. Malaria (1.1 million) WHO, 2002 Drinking Water History Background 1900 Approximately 100 cases typhoid for every 100,000 Americans 1908 First filtration and disinfection of U.S. public water supply in NJ Thousands of U.S. cities begin disinfecting drinking water Dramatic decrease in cases of waterborne illness and death 2006 Approximately 0.1 cases of typhoid for every 100,000 Americans (most due to international travel) One of the greatest public health achievements of the 20 th Century EPA. The History of Drinking Water Treatment: 2000.; CDC. Achievements in Public Health, : Safer and Healthier Foods. MMWR 1999; 48(40): 905.; CDC. Summary of Notifiable DiseasesUnited States, MMWR 2008; 55(53): 17

3 No More Waterborne Disease Issues in the U.S., right? Moving from an Under-Developed to a Developed World Paradigm of Waterborne Disease Tainted Well: Illinois demands answers Water 47 Contract Salmonella From Drinking Legionnaires' bug found in hospital cooling tower Dallas Spends Summer Fighting Crypto and Crypto is Winning Pharmaceuticals Found in Source Water Boil Water Advisory Issued for Nearly 2 million in Massachusetts

4 One Water: The Universe of Water, Sanitation, & Hygiene-Related Disease Water Quality Water Quantity High-medium income Low-income Drinking, Recreational, Security & Response, Other Uses Wastewater, Sanitation, Re-use Hygiene Water, Sanitation, Hygiene Routes of Transmission Ingestion Inhalation Contact (dermal, ear, eye, wound, urinary tract) Nasal

5 Spectrum of Waterborne Disease Acute gastroenteritis Cryptosporidium, toxigenic E. coli, Giardia, Shigella, norovirus, chemicals Skin infections Pseudomonas dermatitis/folliculitis, fungal infections Ear infections Pseudomonas Eye infections and irritation Adenoviruses, chloramines Respiratory infections and irritation Legionella, Mycobacterium, chloramines, chemicals Neurologic infections Echovirus, Naegleria Wound infections Vibrio Hepatitis HAV Urinary tract infections Pseudomonas CHALLENGES TO WATER QUALITY

6 Contamination of Drinking Water Disinfection by-products By-products of chlorine oxidation Environmental contaminants Arsenic, radon Animal-derived contaminants Non-point source contamination Concentrated animal feeding operations Contamination of Drinking Water Human-derived contaminants Wastewater and pathogens Inorganics Heavy metals, nitrates Organics (volatile, non-volatile) Pesticides, herbicides, solvents Pharmaceuticals and personal care products Wastewater plants not equipped to remove themhealth effects unknown at low levels Acute health effects well documented Long-term health effects poorly understood

7 U.S. Drinking Water Systems Aging water and wastewater infrastructure Plants, distribution systems, source water protection, water development > 1 trillion estimate cost, Example: Aging water distribution systems Most systems in U.S. long overdue for replacement ~250,000 annual water main breaks Leaks, breaks, low pressure events open systems to contamination and health effects 60 Number of Waterborne-Disease Outbreaks Associated with Drinking Water, United States, Number of WBDOs SDWA 1974 SDWA 1986 SWTR 1989 GWR Year Yoder et al., MMWR (2008) 57(SS-9): ; N=814

8 U.S. Drinking Water Systems Private wells, small water systems not under SDWA Serve 15.6 million households (~12% of households, ~45 million people) Prone to poor construction, operation, maintenance, water quality WA 2003: most small systems had > 1 system deficiencies that posed a potential public health hazard AL 2005: 40% of private wells failed bacteriologic testing NJ : 12.5% failed testing (2.2% fecal test positive, 2.7% nitrates) Bass Island, Ohio 2004 Resort island900 residents, 500,000 visitors/yr Small treated municipal system and private/public wells Cross connections between municipal system and wells Wells: 76% coliform positive, 30% E. coli + Many residents on septic Inadequte dumping of septage on island Karst limestone geology Role of oversight for these small/private systems

9 Building Issues Building distribution systems premise plumbing Regulation, in practice, stops at the street Biofilms everywhere Pathogens exploiting human-made habitats Niches for thermophiles o Legionella, Mycobacterium avium complex, Acanthamoeba Aerosolization via shower heads, taps Cooling systems create hot water via heat exchange Aerosolization of Legionella Other Uses of Water: Challenges Food production Agriculture: production, irrigation, processing is one of the major uses of water in the world Eat the food and drink the water from around the world Water suspected in Cyclospora outbreaks Spinach and E coli O157:H7, CA 2007 Drawing from decreasing water resource that may be more prone to contamination Increasing re-use of wastewater & graywater

10 Other Water Challenges Biofilms Healthcare Medical devices (e.g., catheters), dialysis, therapy pools Drinking/cooling Distribution systems, premise plumbing Recreational Spas, pools Leisure Foot spas U.S. Wastewater On-site wastewater system failures Reuse/recycle inevitabilities Sludge disposal Farmers encouraged to use as fertilizer o Pathogens, chemicals, drugs, hormones, heavy metals Use/management of animal waste GA 2007: $2 million settlement biosolids from city which contained industrial sewage. Grass and > 100 cows killed---contained

11 Recreational Water: Natural Waters EPA regulates EPA validating new fecal indicators Critical issue is the lack of differentiation between animal and human fecal contamination Many beaches likely closed due to bird contamination Link to human illness is unclear compared to human sewage contamination Illness Incidence and Adjusted Cumulative Incidence Ratios (acir) Comparing Swimmers With Nonswimmers Only one reported Great Lakesassociated outbreak since 1978 Illness acir (95% CI) GI 1.4 ( ) Rash 1.4 ( ) Earache 1.6 ( ) Four Great Lakes Beaches. 21,015 interviews Wade et al., Epidemiol 2008;19:

12 Recreational Water: Chlorinated Venues Little federal regulation Disparate regulation at state, local level Highest use, highest number of outbreaks Little funding for public health research Recreational Water Illness Outbreaks, United States, * Gastroenteritis Number of Outbreaks Year * N=335, includes preliminary 2007 and 2008 data (as of 10/14/2009), Yoder JS et al MMWR 57(SS-9):138.

13 Recreational WaterAssociated Outbreaks of Gastroenteritis in Treated Venues* United States, ** Chlorine sensitive: Poor pool operation & maintenance Unknown 8.7% E. coli O157:H7 2.9% Other 3.8% Giardia 2.96% Shigella 6.7% Norovirus 6.7% Cryptosporidium 68.3% * Treated venues: Pools, water parks, interactive fountains ** N=104, Yoder JS et al MMWR 57(SS-9):138. Other includescampylobacter, Salmonella, Plesiomonas, mixed pathogens Chlorine resistant What is Happening with Cryptosporidiosis Reporting?

14 Cryptosporidiosis Non-Outbreak Case Reports: United States, Number of Case Reports Est. 840,000 cases/year Report Year *Yoder JS, Harral C, Beach MJ. MMWR (2010) 59(SS-6): Cryptosporidiosis Incidence: United States, Cryptosporidiosis Incidence//100,000 < >3.6

15 2004 Cryptosporidiosis Incidence: United States, Cryptosporidiosis Incidence//100,000 < > Cryptosporidiosis Incidence: United States, Cryptosporidiosis Incidence//100,000 < >3.6

16 2004 Cryptosporidiosis Incidence: United States, Cryptosporidiosis Incidence//100,000 < >3.6 Increases in Cryptosporidiosis Reporting: Hypotheses Real increase in transmission Changing testing practices resulting from new drug approval New drug approved for adult use in 2005 (only drug ever approved) More requests for crypto testing because of treatment availability Combination of above More case reports means more DOH follow-up and outbreak detection

17 EFFECTS OF CLIMATE VARIABILITY ON WATER QUALITY AND QUANTITY Climate Change and Water Impacts Increased water availability Moist tropics and high latitudes Decreased water availability Mid-latitudes, semi-arid low latitudes Water stress for hundreds of millions Extreme weather events Droughts, floods, increased temperatures Water quantity as well as water quality becomes issue

18 Drought Surface water Concentration of contaminants Decreased dilution factor in outflows, run-off Groundwater Increasing groundwater recharge Surface water used to recharge Changing soil/geology increases potential for contamination Saltwater intrusion into groundwater as levels drop Current problems TX to CA Southeastrainfall near normal for the first time in years Water Re-Use Indirect potable water reuse -to- Orange County, CA: 70 mgd Salt water intrusion Gwinnett County, GA: 60 mgd Palm Beach, FL, wetlands filtering 10 mgd Aquifer depletion and recharge Land subsidence (San Joaquin Valley, CA) Recharge basins percolate CO river water back into aquifers (Tucson, AZ)

19 Floods Potential infrastructure failures of drinking/ wastewater treatment Sewer overflows (combined and sanitary) >1 trillion gal of sewage & storm water discharged annually during Agricultural and livestock areas rinsed into surface water--- Water quality Surface & ground water contamination w/ pathogens, chemicals Extreme Precipitation and Waterborne Disease Outbreaks in the United States, % of WBDO preceded by precipitation above the 80th percentile, p < % of preceded by precipitation above the 90th percentile, p < Surface water-related outbreaks 1 month after extreme precipitation Groundwater-related outbreaks 2 months after extreme precipitation. Curriero et al AJPH 2001:91;

20 Extreme Weather Events Hurricanes Gustav and Ike, 2008 Millions without electricity Pumping stations and lift stations with no power Drinking water and wastewater treatment impacted Flooded wells Boil water advisories 1993 Midwest flood well data 9 states, widespread contamination, long-term water quality issues with wells Higher Temperatures Increasing water temperatures and/or nutrients Movement of pathogens to more northern regions Vibrio paraheamolyticus in Alaska Enhanced growth of pathogens Naegleria, Vibrio, harmful algal blooms, Pseudomonas Recreational water climate change indicators Increased water use resulting in increased infections, health effects

21 WHAT IS WATERBORNE DISEASE COSTING THE U.S.? Hospitalization Costs of Waterborne Disease Giardia 1,772-6,708 hospitalizations/yr ( /100,000) Average $9,417/hospitalization U.S. cost $17-$63 million Cryptosporidium 1,734-6,779 hospitalizations/yr (6-22/100,000) Average $21,433/hospitalization U.S. cost $37-$145 million Legionella 2,958-9,371 hospitalizations/yr (6-22/100,000) Average $34,279/hospitalization U.S. cost $188-$622 million Total: $ M, $ Medicare/Medicaid Collier et al., in preparation; $2007

22 Economic Analysis of Salmonella typhimurium outbreak, Alamosa, COMarchApril 2008 Contaminated municipal drinking water system 434 illnesses, 18 hospitalized, 1 death Governor declared State of Emergency Bottled Water Advisory and Do Not Use Order Issued Water trucked in by National Guard >$450,000 in response costs Brunkard, Ailes, Collier et al., unpublished Summary Changing face of waterborne disease Increasing importance of outbreaks associated with groundwater and private systems Increasing importance of premise plumbing/biofilms Increases in recreational water assoc. outbreaks Challenges Aging drinking water infrastructure Increasing complexity of chemical contamination New pathogens, chlorine tolerance Severe weather effects, water scarcity and re-use Water used in food production Water jurisdictions generally spread across public health groups or separate agencies

23 Future Needs Accurate burden estimate for all WB disease Cost estimates Investment in drinking water infrastructure National prevention network (WaterNet) needed Active surveillance for waterborne disease NORS in place Improved detection/investigation/reporting Molecular lab-based systems (i.e., CryptoNet) Health effects studies Lab methods development Intervention testing Health promotion/communication activities Foundational Projects to Support Creation of WaterNet WBDOSS Surveillance Improved outbreak detection, investigation, reporting Expanded WBDOSS scope to meet prevention needs Launch of NORS-Water Improved risk factor data Information Build Healthy Water website to support One Water concept Magnitude and Burden National Waterborne Disease Estimate underway Similar methodology as foodborne estimate 48 pathogens (all transmission routes) Economic analyses Common WB disease healthcare costs Outbreak costs

24 Acknowledgements Waterborne Disease Prevention Branch Elizabeth Ailes Joan Brunkard Sarah Collier Caryn Coln Michele Hlavsa Catherine Hough Charles Otto Anu Rajasingham Virginia Roberts Sharon Roy Kelly Stimpert Jay Watson Jonathan Yoder NCEH/EHSB Charles Otto "The findings and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency Questions? More Information: Healthy Water Website Michael Beach: National Center for Emerging and Zoonotic Infectious Diseases Division of Foodborne, Waterborne, and Environmental Diseases