1. 3.2 Environmental transmission of pathogens Where do the pathogens come from? How do pathogens in excreta contaminate the environment? Learning objective: to become familiar with environmental transmission routes for pathogens, especially in relation to water and sanitation. Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

2. Infectious disease outbreak among 100 persons 100 persons in a small community were affected by severe diarrhoea, ten of whom were hospitalised At the lab: isolation of bacteria in the patients stool and proved to be the same- EHEC! Interviews showed that all had eaten e.g. raw lettuce From where did this bacteria strain come? At the lab: these EHEC bacteria were also found in samples of irrigation water - and also in a stream What brought EHEC to the lake? Grass on the grazing fields had EHEC Why were the cows not sick? Cows were infected, but without symptoms From where did cows get infected by EHEC? etcetera Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

3. 1. Run-off from agricultural land grazed by cattle infected with EHEC 3. Irrigation of lettuces (no requirement for analysis of the water) 4. The lettuce was consumed by a large number of individuals – resulted in 100 cases (some 10 hospitalised) At the lab: isolating and comparing bacteria in samples from patients and in water samples An example of zoonosis i.e. transmission from-animal-to-human Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden : 2. Manure runoff to river water

4. Zoonoses Transmission humans animals May cause symptoms or not in animal Vectors Insects, rodents, birds – mechanical transport Birds, wild and domestic animals infected without symptoms Intermediate host Animal necessary for lifecycle of pathogen, e.g. malaria, schistosomiasis Transmission by animals Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

5. Features of excreta - hygiene Urine Sterile in body Naturally containing some bacteria after excretion Few diseases transmitted by urine Low risk to handle Faeces Naturally containing high amounts of bacteria Many diseases transmitted by faeces (faecal-oral) May contain pathogenic bacteria, viruses, protozoa or helminths Significant risk to handle Microorganisms in excreta Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

6. (Esrey et al. 1998) The ”F-diagram” - main routes for the spread of diarrhoea

7. Excreta from humans & animals Humans Shellfish Crops Aerosols Oceans and Estuaries Oceans and Estuaries Rivers and Lakes Rivers and Lakes Irrigation Solid Waste Landfills Solid Waste Landfills Sewage Land Runoff Land Runoff Recreation Water Supply Water Supply Groundwater Adapted from Gerba et al. 1975 1 432 8 76 5 12 10 9 13 11 Transmission routes for pathogens in human excreta

8. May contain bacteria, viruses, parasitic protozoa and helminths that cause infections Diarrhoeal disease is the main concern Faeces should be considered a health hazard Need to be treated before use as a fertiliser Easier to handle and treat if diverted from other waste fractions Pathogens in faeces Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

9. Origin Birds and other animals Recreational use Industrial effluent Stormwater and surface water Agricultural runoff and effluent Domestic sewage Leachate Sea Sources of faecal indicator bacteria Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

10. Urine is sterile in the bladder Freshly excreted urine contains <10 000 bacteria/ml Urinary tract infections - not transmitted through the environment Leptospira interrogans - low prevalence Salmonella typhi, Salmonella paratyphi - developing countries, faecal-oral transmission more common Schistosoma haematobium - fresh water snail needed for development low risk for transmission of infectious diseases through urine Microorganisms in urine Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

11. Faeces the main source of pathogens that cause enteric infections Urine only a few diseases transmitted through urine Greywater e.g. laundry, washing diapers, from food stuffs Industry abattoir, food industry (plant pathogens) Storm water e.g. surface run-off – animal faeces Origin of pathogens in wastewater - contribution from different waste fractions Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

12. Ecological Alternatives in Sanitation

13. Contamination of groundwater Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

14. Contamination of drinking water Drinking water quality Heterotrophic bacteria, E. coli, metals, nitrate (other aspects are smell, colour) Contaminated surface- or groundwater Wastewater outlet, latrines, run-off Contamination during distribution Growth in pipes, intrusion of wastewater Contamination of finished water During storage and handling, e.g. reservoirs, vendors Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

15. Local environmental pollution Accidental exposure High risk of down-stream pollution Exposure from e.g. swimming and intended household use Pollution of drinking water sources Surface run-off and ground water infiltration Contamination of irrigated crops Exposure during irrigation and at consumption Health risks related to untreated wastewater Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

16. Excretion of pathogens in faeces Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

17. Pathogens in urine and importance of urine as a transmission route Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

18. Small volumes of faeces contaminates large volumes of clean water Collection from a large number of persons – pathogens continuously present Smaller systems – higher concentration of a specific pathogen Treatment not optimized for killing pathogens 10% of wastewater is treated (developing countries) 20 million ha (?) irrigated with wastewater Pathogens in mixed wastewater Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

19. Lower concentrations of pathogens here than in faeces Faecal origin of pathogens ( bathroom and laundry ) Shower and bath, washing clothes, washing diapers Pathogens from food stuffs ( kitchen sink ) Faecally contaminated vegetables (e.g. from irrigation with wastewater or application of animal manure), soil Contaminated meat (e.g. chicken) Health risk from disposal or reuse Contamination of nearby surroundings Contamination of drinking and recreational water Irrigation of crops Pathogens in greywater Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

20. When treating wastewater, pathogens are being concentrated in the sludge – not in the effluent Typical concentrations of microorganisms in sludge [per g wet weight] (EC, 2001) Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

21. Possible transmission routes for pathogens from organic fertilisers (e.g. faeces) Handling on site The handling and reuse of all types of waste products with human or animal origin involve hygienic risks Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

22. Contamination of food Contaminated seeds, uptake of pathogens? Organic fertilisers – human excreta, wastewater, animal manure Irrigation – wastewater, contaminated surface water Handling and storage Cooking Storing of cooked food, growth of pathogens Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden

23. Waterborne diseases and sanitation Waterborne diseases are caused by: - ingestion of water contaminated by human or animal faeces or urine containing pathogenic bacteria or viruses. - they include cholera, typhoid, amoebic and bacillary dysentery and other diarrhoeal diseases. Sanitation system that involve reuse need to prevent disease transmission, mainly by: - protecting ground- and surface water - safe handling and use of the waste products in agriculture Caroline Schönning, Swedish Institute for Communicable Disease Control, Solna, Sweden