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TITLE from VIEW and SLIDE MASTER | November 4, 20131 |

Water and Wells: The Health connection:

“Wells to reduce waterborne diseases andThe role of Information transfer in disease prevention”

Water and Wells: The Health connection:

“Wells to reduce waterborne diseases andThe role of Information transfer in disease prevention”

Aileen M Marty MD, FACPProfessor, Infectious Diseases,

Department of Medicine, HWCOM [email protected]

TITLE from VIEW and SLIDE MASTER | November 4, 20132 | 2010 Team SA

Introduction: Water = Life

What is in the water?

Water and Health

Wells and Water: Altering evolutionary pressure

Information transfer and disease prevention

Summary

Outline

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Water is essential for all living things on this Earth, Water is filled with living things, and

all living things are filled with water

Introduction

Unclean water and lack of water are major health hazards* ~1.1 billion people have no sanitation facilities at all and practice

open defecation (WHO/UNICEF 2012)

* ~ 783 million people do not have access to improved drinking water sources (WHO/UNICEF 2012).


Water In War-torn area Middle EastWater In War-torn area Middle East

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Toxins, metals, salts

Living things

Radiation

Man-Made Garbage (e.g. plastics, oil spills, BW/CW agents, etc.)

What is in the water?

Microbes, Plants, and Animals (from Sponges to Vertebrates):

& their products (excreta, toxins, gases, etc.)

Viruses, bacteria, fungi, protozoa, and helminths

Seafood, including Contaminated seafood

Predatory and toxic sea life

Growing and developing vectors of disease


Type of Disease Description

Waterborne• Diseases transmitted by swallowing contaminated drinkingwater. Examples: cholera, typhoid

fever, cryptosporidiosis, botulism, toxins in water (e.g. Arsenic), cryptosporidiosis

Water‐carried

• Diseases acquired by accidental drinking, inhaling, or exposure to, contaminated recreational

water. Examples: cryptosporidiosis, giardiasis, Pseudomonas dermatitis, Free‐living amoeba,

Vibrio vulnificus in seawater

Water‐unwashed

• Diseases transmitted as a result of poor sanitation from inadequate quantities or quality of

water for washing hands, utensils, meats, vegetables, etc. Examples: shigellosis, hepatitis A,

hepatitis E, cyclosporiasis

Water‐based• Diseases by pathogens with an obligatory life‐cycle phase in creature that lives in water.

Examples: Diphyllobothrium infection, schistosomiasis, dracunculiasis, fascioliasis, anisakiasis

Water‐life carried• Diseases by pathogens that infect sea‐life, but are not obligatory life‐cycle phase‐based

pathogens. Examples Enteric viruses in shellfish, Hepatitis A or Vibrio vulnificus in Oysters

Water‐droplet inhaled or sully wound/mucosa

• Disease by pathogens carried in water vapor and inhaled or contaminatewound or via mucosa

Example: Legionellosis, meliodosis, Buruli ulcer

Water‐vectored• Diseases transmitted by arthropods that breed or bite in or near water Examples: yellow fever,

dengue, malaria, onchocerciasis, African trypanosomiasis, Loiasis

Water‐infected

• Diseases transmitted by preharvest pathogen contamination of edible portions of plants with

impure water, via their root systems (and to less degree via leaves). Example Escherichia coli

O157:H7, Salmonella, and Listeria monocytogenes,

Toxic Water Creatures• Disease from consuming sea‐life that produces or has ingested toxins (Biomagnification)

Examples: Puffer fish, Mercury in Fish, Ciguatera in Fish

Dangerous Marine life• Sea creatures may attack / defend themselves Examples: Sharks, electric eels, sting rays,

jellyfish

Water‐accident• Trauma/injury related to water‐related activities/accidents, or Examples: boating injuries,

drowning, bang‐stick accident, Spearfishing accident, etc.

Water quantities • Too much or scarcity of water. Examples: drowning, flooding, dehydration, overhydrating, etc.

Water and Health: Risks

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It’s not all diarrhea…It’s not all diarrhea…


Legionella species Common in outdoor reservoirs e.g. lakes or streams

Colonize and amplify in artificial water reservoirs e.g. potable water systems, cooling towers

Inhalation of water droplets with Legionella species Legionnaires’ disease Infections increase with wet humid weather

80% of Legionnaires’ disease outbreaks are associated with potable water systems in buildings

Water in buildings originates in outdoor reservoirs, as temperatures rise, more grow in pipes

~ 18,000 cases of Legionaries disease in USA/year

• 20% fatal if community acquired, 40% fatal if hospital acquired

Legionella spp. and Climate Change

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Transmission EM of Hartmannella vermiformis (A and B) and Human alveolar epithelial cells (C and D)Both are infected with L. pneumophila [at 4 h (A and C) and 12 h (B and D) post-infection]

Abu Kwaik Y et al. Appl. Environ. Microbiol. 1998;64:3127-3133

Legionella spp. can multiply intracellularly within protozoa


Oysters: Pearls and Perils

• Many studies report detection of pathogens from shellfish harvested in areas considered unpolluted

• Hepatitis• Norovirus• Adenovirus• Vibrio species• Salmonella enterica serotype Typhi

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Capillaria philippinensis – care for a little sushi?


Helicobacter PyloriHelicobacter Pylori

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Acute gastritis

Chronic gastritis

Atrophic gastritis

Hemorrhagic gastritis

Peptic ulcers

Acne rosacea?

Intestinal metaplastic atrophic gastritis

Reactive lymphoid hyperplasia

Mucosa-associated lymphoid tissue [MALT] lymphoma

Neoplasms?

Inflammatory and Neoplastic Lesions of Helicobacter pylori

Posselt et al. Cell Communication and Signaling 2013 11:77 doi:10.1186/1478-811X-11-77


Cryptosporidium (to Contrast With Cyclosporidium

Cryptosporidium (to Contrast With Cyclosporidium

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CyrptosporidiumCyrptosporidium


Routes for Fecal Contamination to Enter Humans

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In a Town in Hispanola With No Latrine

In a Town in Hispanola With No Latrine


Direct and Indirect Effects of Water issues on Growth and Development Direct and Indirect Effects of Water issues on Growth and Development

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Pathogen Infectious Dose 50

(# of Organisms)Shigella 10 to 102

EHEC Unknown (likely low)Campylobacter jejuni 102 to 106

Salmonella 105

Non-EHEC 108

Vibrio cholerae 108

Giardia lamblia 10 to 102 cystsEntamoeba histolytica 10 to 102 cystsCryptosporidium parvum 1 to 103 oocysts

ID50 for Representative Enteric Pathogens


THE INTESTINAL BARRIER

THE INTESTINAL BARRIER

Physical barrier:– Separates intestinal lumen from lamina

propria

– Biologically active• Changes daily and over years

– Has mucous coat: composed of mucins

– Motility

Three barriers Three barriers in 1:1. Physical barrier

• Non-immune barrier molecules

• Mechanical barrier

2. Innate immune barrier 3. Adaptive immune barrier.

3 FOR THE PRICE OF ONE!

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Surface and Mucosal Immunity to PathogensSurface and Mucosal Immunity to Pathogens

• Surfaces that confront outside side world • Skin

– Unique attributes Keratinized surface

Unique cells

Constantly exposed to microbes

• Mucosal areas– Components

GI

GU

Respiratory

Other: Eye, lactating breast, Ear

– Unique Attributes Unique cells

Constantly exposed to

» Secretory IgA

» Other secreted Ig

» Microbes (good & bad)


Serious Diseases

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Interrelated aspects of Infectious Disease

Properties of the organism (innate/acquired)

Properties of host (innate/acquired)

Physical factors: properties of the environment/micro-environment, season of year, dose received

“All Creatures Great and Small”

The three variables determine if an exposure/infection leads to clinical disease


Evolutionary Conflicts of Interest: – Needs of Host versus Needs of Pathogen

Pathogens evolve so that they can maximize their chance of growth and transmission

– Need Host for transmission decrease virulence

– Need water w/o host for transmission increase virulence

Natural selection is powerless to favor long-term stability if the variants that win in the short term destabilize the system

Wells and Water; Altering evolutionary pressure

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If contaminated water easily reaches the next victim, then the more virulent organism has an advantage

Waterborne Organism Waterborne Organism


Mortality and Waterborne nature of transmission of bacterial diarrheal diseases

Mortality and Waterborne nature of transmission of bacterial diarrheal diseases

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From Peru to neighboring nations, each with different levels of water sanitation/ safety

Vibrio cholerae

Vibrio cholerae

TITLE from VIEW and SLIDE MASTER | November 4, 201328 | 2010 Team SA Good Water Management System Decrease virulence

Virulence of Vibrio cholerae in Chile Virulence of Vibrio cholerae in Chile

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TITLE from VIEW and SLIDE MASTER | November 4, 201329 | 2010 Team SA Medium Water Management System No change in virulence

Virulence of Vibrio cholerae in PeruVirulence of Vibrio cholerae in Peru

TITLE from VIEW and SLIDE MASTER | November 4, 201330 | 2010 Team SA Poor Water Management System Increase in virulence

Virulence of Vibrio cholerae in EcuadorVirulence of Vibrio cholerae in Ecuador

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Changes in Virulence Alter Risk of Development of Antibiotic Resistance


Changes in Virulence alter risk of Antibiotic Resistance

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Sensitivity of Vibrio cholerae to Tetracycline1991-1993


Sensitivity of Vibrio cholerae to Tetracycline1997-1999

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Mosquito Problem Malaria ProblemAlabama 1940’s after creation of Wilson Dam


Plasmodium infection in Alabama pre and post use Mosquito proofing homes, offices, hospitals

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Information Transfer and Water Health IssuesInformation Transfer and Water Health Issues


More people have access to safe drinking water & sanitation but population growth eclipses these accomplishments 1/6 (1.1 billion) of world population lacks access to improved water supply, 2/5 (2.4 billion) have no improved

sanitation. Most of these people live in Asia and Africa. Rural services lag far behind urban services

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World Water Day - 22 March (every year since 1992)

UN-Water Activity Information System (UNW-AIS)

GEF IW:LEARN (International Waters Learning Exchange & Recourse Network)

Stakeholder Dialogues / Communications / Agreements


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UN-Water: – Members: 31 United Nations Organizations are members

• responsible for major funds and programs, specialized agencies, regional commissions, United Nations conventions and other entities within the UN system.

– Special Partners: 5 partners with Special Status

– Partners, General: 23 non-UN partner organizations


Thickness of line represents quantity of common activities between members & partners

UN-WaterUN-Water

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Type of Disease Description

Waterborne• Diseases transmitted by swallowing contaminated drinkingwater. Examples: cholera, typhoid

fever, cryptosporidiosis, botulism, toxins in water (e.g. Arsenic), cryptosporidiosis

Water‐carried

• Diseases acquired by accidental drinking, inhaling, or exposure to, contaminated recreational

water. Examples: cryptosporidiosis, giardiasis, Pseudomonas dermatitis, Free‐living amoeba,

Vibrio vulnificus in seawater

Water‐unwashed

• Diseases transmitted as a result of poor sanitation from inadequate quantities or quality of

water for washing hands, utensils, meats, vegetables, etc. Examples: shigellosis, hepatitis A,

hepatitis E, cyclosporiasis

Water‐based• Diseases by pathogens with an obligatory life‐cycle phase in creature that lives in water.

Examples: Diphyllobothrium infection, schistosomiasis, dracunculiasis, fascioliasis, anisakiasis

Water‐life carried• Diseases by pathogens that infect sea‐life, but are not obligatory life‐cycle phase‐based

pathogens. Examples Enteric viruses in shellfish, Hepatitis A or Vibrio vulnificus in Oysters

Water‐droplet inhaled or sully wound/mucosa

• Disease by pathogens carried in water vapor and inhaled or contaminatewound or via mucosa

Example: Legionellosis, meliodosis, Buruli ulcer

Water‐vectored• Diseases transmitted by arthropods that breed or bite in or near water Examples: yellow fever,

dengue, malaria, onchocerciasis, African trypanosomiasis, Loiasis

Water‐infected

• Diseases transmitted by preharvest pathogen contamination of edible portions of plants with

impure water, via their root systems (and to less degree via leaves). Example Escherichia coli

O157:H7, Salmonella, and Listeria monocytogenes,

Toxic Water Creatures• Disease from consuming sea‐life that produces or has ingested toxins (Biomagnification)

Examples: Puffer fish, Mercury in Fish, Ciguatera in Fish

Dangerous Marine life• Sea creatures may attack / defend themselves Examples: Sharks, electric eels, sting rays,

jellyfish

Water‐accident• Trauma/injury related to water‐related activities/accidents, or Examples: boating injuries,

drowning, bang‐stick accident, Spearfishing accident, etc.

Water quantities • Too much or scarcity of water. Examples: drowning, flooding, dehydration, overhydrating, etc.

Water and Health: Risks

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Water and Health: PreventionType of Disease Interception

Waterborne• Provide clean drinking water

Water‐carried• Inform about contaminated water areas, who is and who is not at risk from certain organisms

in water, clean and monitor swimming pools

Water‐unwashed • Provide clean water for sanitation of persons, animals, foods, and things

Water‐based• Interrupt the life cycle (e.g. do not allow contaminated persons to place their body

parts/fluids in water source for other host species)

Water‐life carried• Clean up natural reservoirs, avoid polluting waters

Water‐droplet inhaled• Clean up natural reservoirs, assure clean water in air‐condition units, air‐filters

Water‐vectored• Control of vectors (mosquito nets, biologic control)

Water‐infected• Assure clean water for crops

Toxic Water Creatures• Inform and Avoid seafood known to contain toxins, have food prepared by expert Fugu chef

Dangerous Marine life• Inform and Avoid areas with aggregates of dangerous animals, use shark‐repellant,

Water‐accident• Inform and Follow Standard precautions as per sport/activity,

Water quantities

• Inform and Evaluate Risks; engineering solutions to provide sufficient water and structures to

prevent flooding, building codes, desalinization, water‐rights issues/political negotiations


Water Health is a multifaceted problemthat requires a multifaceted approach involving diverse specialists

Beware of potential unintended consequences

Harness Evolutionary Pressures

Health Promotion for Water Safety Requires Knowledge transfer to

– Policy makers

– Health care workers

– Engineers, Scientists, Architects, Developers

– The public

SummarySummary

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Questions? Questions? Questions? Questions? Questions? Questions?

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