Effets sur la santé de la recroissance bactérienne dans les eaux de consommation / Health significance of bacterial regrowth in drinking water [Tribune libre, texte anglais et français]

La présence de bactéries hétérotrophes dans les eaux de consommation (robinet filtrée sur unités domestiques ou embouteillées) constitue un problème difficile à résoudre car on connaît très mal leurs effets sur la santé humaine. Deux points de vue s'affrontent: l'une perçoit ces bactéries comme des bactéries sans aucune importance quel que soit leur nombre, l'autre suppose que certaines d'entre elles sont potentiellement pathogènes et que l'on ne doit pas leur permettre de se multiplier indûment dans l'eau de consommation.Ces bactéries hétérotrophes sont présentes partout et elles trouvent dans l'eau de consommation une niche écologique qui permet parfois leur croissance en grand nombre (e.g., nodules du réseau, tuyauterie des maisons, chauffe-eau, eaux embouteillées, filtre à charbon actif, etc.). Elles ne sont généralement pas d'origine fécale et ne peuvent donc pas servir d'indicateur de pollution fécale. De plus, les indicateurs fécaux tels les coliformes ou Escherichia coli ne peuvent servir à décrire ce groupe de bactéries. Des études réalisées aux États-Unis chez des familles consommant de l'eau filtrée sur filtres à usage domestiques n'ont pas mis en évidence d'effet sur la santé de concentrations élevées de bactéries hétérotrophes. D'autres études ont suggéré qu'une forte croissance de ces bactéries pouvait même être inhibitrice de la croissance des coliformes fécaux et de certaines bactéries pathogènes. Enfin, on a mis en évidence dans certains cas un effet inhibiteur de la présence de grand nombre de ces bactéries lors de l'énumération des bactéries indicatrices par filtration sur membrane. Au contraire, des études canadiennes récentes suggèrent que la présence de bactéries hétérotrophes en grand nombre pourrait avoir des effets sur la santé des consommateurs d'eau. Ces effets ont été observés lors de la prolifération de la flore bactérienne hétérotrophe dans les réservoirs d'unités de filtration par osmose-inversée. Enfin, des bactéries possédant des facteurs de virulence, et pouvant donc initier des maladies, ont été identifiées dans les eaux de consommation et posent le problème sous un angle nouveau.Les indicateurs dont nous disposons pour évaluer les effets sur la santé des eaux de consommation sont de plus en plus remis en question. Les indicateurs de pollution fécale étant inadéquats pour l'évaluation des risques sur la santé il faudra maintenant nous tourner vers d'autres méthodes pour la surveillance des risques associés à la consommation d'eau. n est très difficile avec les informations dont nous disposons maintenant, de définir si l'on doit réglementer le nombre de bactéries hétérotrophes ou si l'on doit tout simplement faire tous les efforts pour éviter les recroissances non-contrôlées.The presence of heterotrophic bacteria in drinking water (tap, point-of use treated or bottled) poses a difficult problem because we do not clearly know if they are really innocuous. Two points of views are presented: they could be totally unimportant whatever their number or they can be opportunistic pathogens and even frank pathogens if they are allowed to multiply in large numbers. These bacteria are not of faecal origin and are not indicators of faecal pollution even if occasionally some can be described as coliforms. Studies in the United States on families drinking water from domestic filtration units did not observe any significant health effects while other researchers have observed an inhibitory effect of these heterotrophic bacteria on coliforms and some pathogenic bacteria. On the other band, recent Canadian studies have observed that high bacterial counts in the water produced by reverse-osmosis units were correlated to gastrointestinal illnesses and that bacteria of potential virulence were present in tap water. All these observations have brought back the question of the potential health effects of heterotrophic bacteria. At the same time, the ability of current water quality indicators to protect public health is questioned and we must find other methods for the surveillance of waterborne diseases. Within these new guidelines or regulations, will probably have to set a limit on the acceptable number of heterotrophic bacteria in water. What this level will be remains to be determined, but until then we must assume that it is prudent to test drinking water in such a way, that it will not promote or permit the uncontrolled multiplication of bacteria of which we know so little. We are discovering new pathogens each year and we cannot assume that they are not present in treated waters. There are two approaches that can be used to limit potential health risks. The first is to limit the total population of heterotrophic bacteria by limiting available nutrients and using appropriate enumeration methods (heterotrophic plate count or epifluorescence viable counts). The second is to use or develop an indicator of health risk based on the virulence of bacteria (i.e., detection of virulence factors). There are still long discussions and researches ahead, but the driving force will be probably directed at limiting the nutrient available to heterotrophic bacteria and preventing significant growth in water distribution systems

Les contaminants de l'eau et leurs effets sur la santé

La transmission des maladies par la voie hydrique est sous contrôle dans la majorité des pays industrialisés. Malgré tout des maladies épidémiques ou endémiques sont encore observées. Plusieurs microorganismes sont en émergence, et Cryptosporidium a été impliqué dans des épidémies importantes dans plusieurs pays. Le conrôle de ces maladies transmissibles par la voie hydrique requiert des autorités des nouvelles approches qui allient le contrôle des risques de cancer dûs aux sous-produits de la désinfection au contrôle des micro-organismes les plus résistants . Aux Etats-Unis, l'objectif proposé est l'absence de microorganismes dans l'eau potable. Cet objectif ne peut être contrôlé par les indicateurs usuels et l'on recommande donc un niveau de traitement équivalent. Le traitement est alors contrôlé en temps réel par des moyens physico-chimiques tels la turbidité ou la mesure des particules, et un contrôle a posteriori par de nouveaux indicateurs telles les spores des bactéries sporulantes aérobies.Le vieillissement des installations, des populations immunocompromises et une urbanisation grandissante sont autant de causes de l'émergence de nouvelles maladies infectieuses dont certaines transmissibles par la voie hydrique. La proportion des maladies gastro-intestinales qui est attribuable à l'eau de consommation est encore très grande et elle contribue à maintenir ces infections en circulation dans la population. Le dilemme du contrôle des risques de cancer dus aux sous-produits de la désinfection ne doit pas conduire à une réduction de l'efficacité des traitements, car le niveau de risque à partir duquel ont été fixées les concentrations maximales admissibles de ces sous-produits dans l'eau (10-6 cas de cancer par vie entière d'exposition) est bien plus faible que celui de contracter une maladie infectieuse d'origine hydrique en absence de traitement adéquat. La situation en matière de pathologies induites par la consommation d'eau est extrêmement contrastée selon les pays. En effet la transmission de maladies infectieuses par la voie hydrique a été maîtrisée dans la plupart des pays industrialisés par la mise en place d'installations de traitement et d'un contrôle sanitaire s'appuyant sur une réglementation abondante. A l'opposé la situation des pays en voie de développement reste souvent très mauvaise dans ce domaine et l'Organisation Mondiale de Santé estime que 1,5 milliards d'habitants ne disposent pas encore d'eau potable dont cent millions en Europe et que 30 000 morts journalières sont dues à l'absence d'une eau en quantité et qualité satisfaisantes (Ford et Colwell 1996).En revanche les pays développés voient la qualité chimique des eaux distribuées de plus en plus souvent mise en cause par les associations de consommateurs. Outre le progrès très rapide des techniques analytiques qui permet de découvrir la présence de traces dont on ne soupçonnait guère la présence dans l'eau du robinet, la pollution croissante de la ressource, les traitements de désinfection et le contact avec les matériaux des réseaux de distribution apportent des molécules dont la toxicité à moyen et long terme mérite d'être évaluée.La mise en oeuvre de traitements de désinfection dont l'utilité est indiscutable et l'effet sur la morbidité et la mortalité par pathologie infectieuse chez des populations desservies parfaitement significatif, s'accompagne de la formation de sous-produits. Certains de ceux-ci étant cancérigènes et/ou mutagènes en expérimentation de laboratoire et des études épidémiologiques ayant pu montrer une légère augmentation du risque de cancer dans la population, l'impact médiatique de cette information peut conduire à une mauvaise appréciation dans la gestion des risques pour la santé. Ainsi l'arrêt de la chloration pour éviter la formation de sous produits et quelques cas de cancers aurait conduit un pays d'Amérique du Sud a enregistrer une importante épidémie de choléra et des centaines de décès.Il n'est pas facile de gérer ce paradoxe entre sophistication du traitement lié à la pollution de la ressource entraînant la présence de sous produits de désinfection et la persistance d'éléments traces et de divers microorganismes dans une eau de qualité conforme aux critères de potabilité mais que le consommateur ne veut plus consommer. Dans cet article nous tenterons de faire le point sur le risque hydrique pour la santé lié d'une part aux contaminants biologiques et d'autre part aux contaminants chimiques. Sa meilleure connaissance est la clef d'une stratégie de gestion efficace et d'une reconquête du consommateur que la publicité a trop tendance à orienter vers les eaux embouteillées.The transmission of waterborne diseases is now controlled in most developed countries but a residual level of both epidemic and endemic diseases can still be observed. Recent observations have involved emerging pathogens such as Cryptosporidium which has been implicated in several very large outbreaks worldwide. To control these waterborne outbreaks many countries are proposing treatment goals that would achieve a significant reduction in the risk to the population without increasing the risks of cancer due to disinfection by-products. In the United States, the objective is zero pathogen in drinking water. This objective can be approached by appropriate treatment but monitoring cannot be done using the current biological indicators. Reliance on continuous measurement of physico-chemical parameters such as disinfectant residual and contact time, turbidity and particulate measurement in real-time are proposed solutions. Microbiological indicators remain an active mean of controlling afterwards water quality : spores of aerobic or anaerobic bacteria are extremely resistant to treatment and ofter means of assessing removal of pathogens over a range of several order of magnitude.Numerous pathogens have been involved in waterborne outbreaks and some are just emerging. Urbanisation, aging of water treatment plants, the increasing number of immunocompromised individuals are potential causes for increased risk of waterborne infectious diseases. The endemic level of gastrointestinal disease due to drinking water consumption is still significant and could contribute to pathogens in circulation in the populations affected. The dilemma of balancing microbial and cancer health risk remains a difficult one to resolve but it should not result in a reduction of treatment efficiency, because of the low risk-level for cancer used for the Maximum Admissible Concentration (MAC) values (10-6 fall life) as compared to the risk of waterborne infectious disease in absence of adequate water treatment.For setting these MAC values in water it is necessary to consider all sources of exposition of the considered compound and according to is mode of action two ways of evaluation may be followed. The first one, for the molecules with a deterministic effect (or non stochastic effect) the dose-effect relationships dose-effet on individuals and dose responses relationships on populations, are considered, and only no indesirable effect in the consumming population may be accepted. For the second one, for the molecules with a probabilistic (stochastic) effect, (absence of dose-effect relationship but increase of the incidence of cancer or genetic abnormalities in population according to levels of exposure), MAC values are setted by computation off all exposures and considering an accepable risk of apparition of the pathology ranging from 10-5 (WHO) to 10-6 (North America and Europe) for consumption of two liters of drinking water during 70 years.Because of the lack of information about these very conservative approaches, associations of consumers are often misinterpreating : in this situation water is not in accordance with drinking water standards but may be used during a short period without any risk increase for the population. Examples are developped in this paper with description of hazards due to nitrate, nitrite, pesticides and desinfection by-products which are actually frequently associated with debates within water specialists, politicians and consumers.If situation is now more clearly defined for nitrates and pesticides, the lack of scientific information for the effects of bromates combined with the conservative approach for the molecules with "probabilistic" effect, leads to a severe MAC value in comparison with the analytical capacities of laboratories and technical data of water desinfection both with ozone and bleaching agent.This situation may not lead to the diminution of adequate desinfection water treatment because of the consequences on the increase of the risk of waterborne infectious disease. More progresses are needed, both in terms of knowledges in toxicological and epidemiological data and technological ways of treatment, for being able to produce safe drinking water, with a taste and a price acceptable for the consumer. But the levels of risk considered for setting standards insures that drinking water is one of the safer products offer for consumption

Brote de gastroenteritis por agua potable de suministro público

ResumenIntroducciónLa potabilidad del agua induce a descartar el posible origen hídrico de los brotes. El objetivo fue investigar un brote de gastroenteritis por agua potable de suministro público.MétodosDespués de la notificación de un brote de gastroenteritis en el municipio de Baqueira (Valle de Arán) se diseñó un estudio epidemiológico de cohortes retrospectivo. Mediante un muestreo sistemático se eligió a 87 personas hospedadas en los hoteles y a 62 alojadas en diferentes apartamentos. Se recogió información sobre 4 factores (consumo de agua de la red, bocadillos, agua y alimentos en las pistas de esquí) y presencia de síntomas. Se determinó la existencia de cloro, se analizó el agua de la red y se realizó un coprocultivo a 4 enfermos. La implicación de cada factor se determinó con el riesgo relativo (RR) y su intervalo de confianza (IC) del 95%.ResultadosLa incidencia de gastroenteritis fue del 51,0% (76/149). Los porcentajes de los síntomas fueron los siguientes: fiebre, 27,0%; diarrea, 87,5%; náuseas, 50,7%; vómitos, 30,3%, y dolor abdominal, 80,0%. El único factor que presentó un riesgo estadísticamente significativo fue el consumo de agua de la red (RR = 11,0; IC del 95%, 1,6-74,7). La calificación sanitaria del agua fue de potabilidad. Se observó un defecto de situación del clorador en el depósito, que fue corregido. Se recomendó incrementar aún más las concentraciones de cloro, lo cual se acompañó de una disminución de los casos. Los coprocultivos de los 4 enfermos fueron negativos para las enterobacterias investigadas.ConclusionesEl estudio demuestra la posibilidad de presentación de brotes hídricos por agua cualificada como potable y sugiere la necesidad de mejorar la investigación microbiológica (determinación de protozoos y virus) en este tipo de brotes.AbstractIntroductionThe chlorination of public water supplies has led researchers to largely discard drinking water as a potential source of gastroenteritis outbreaks. The aim of this study was to investigate an outbreak of waterborne disease associated with drinking water from public supplies.MethodsA historical cohort study was carried out following notification of a gastroenteritis outbreak in Baqueira (Valle de Arán, Spain). We used systematic sampling to select 87 individuals staying at hotels and 67 staying in apartments in the target area.Information was gathered on four factors (consumption of water from the public water supply, sandwiches, water and food in the ski resorts) as well as on symptoms. We assessed residual chlorine in drinking water, analyzed samples of drinking water, and studied stool cultures from 4 patients. The risk associated with each water source and food type was assessed by means of relative risk (RR) and 95% confidence intervals (CI).ResultsThe overall attack rate was 51.0% (76/149). The main symptoms were diarrhea 87.5%, abdominal pain 80.0%, nausea 50.7%, vomiting 30.3%, and fever 27.0%. The only factor associated with a statistically significant risk of disease was consumption of drinking water (RR = 11.0; 95% CI, 1.6-74.7). No residual chlorine was detected in the drinking water, which was judged acceptable. A problem associated with the location of the chlorinator was observed and corrected. We also recommended an increase in chlorine levels, which was followed by a reduction in the number of cases. The results of stool cultures of the four patients were negative for enterobacteria.ConclusionsThis study highlights the potential importance of waterborne outbreaks of gastroenteritis transmitted through drinking water considered acceptable and suggests the need to improve microbiological research into these outbreaks (viruses and protozoa detection)

Selection and assembly of indigenous bacteria and methanogens from spent metalworking fluids and their potential as a starting culture in a fluidized bed reactor

Waste metalworking fluids (MWFs) are highly biocidal resulting in real difficulties in the, otherwise favoured, bioremediation of these high chemical oxygen deman (COD) wastes anaerobically in bioreactors. We have shown, as a proof of concept, that it is possible to establish an anaerobic starter culture using strains isolated from spent MWFs which are capable of reducing COD or, most significantly, methanogenesis in this biocidal waste stream. Bacterial strains (n=99) and archaeal methanogens (n=28) were isolated from spent MWFs. The most common bacterial strains were Clostridium species (n=45). All methanogens were identified as Methanosarcina mazei. Using a random partitions design(RPD) mesocosm experiment, we found that bacterial diversity and species–species interactions had significant effects on COD reduction but that bacterial composition did not. The RPD study showed similar effects on methanogenesis, except that composition was also significant. We identified bacterial species with positive and negative effects on methane production. A consortium of 16 bacterial species and three methanogens was used to initiate a fluidized bed bioreactor (FBR), in batch mode. COD reduction and methane production were variable, and the reactor was oscillated between continuous and batch feeds. In both microcosm and FBR experiments,periodic inconsistencies in bacterial reduction in fermentative products to formic and acetic acids were identified as a key issue

Reducing potentially preventable complications at the multi hospital level

Contains fulltext : 96269.pdf (publisher's version ) (Open Access)ABSTRACT: BACKGROUND: This study describes the continuation of a program to constrain health care costs by limiting inpatient hospital programs among the hospitals of Syracuse, New York. Through a community demonstration project, it identified components of individual hospital programs for reduction of complications and their impact on the frequency and rates of these outcomes. FINDINGS: This study involved the implementation of interventions by three hospitals using the Potentially Preventable Complications System developed by 3M Health Information Systems. The program is noteworthy because it included competing hospitals in the same community working together to reduce adverse patient outcomes and related costs.The study data identified statistically significant reductions in the frequency of high and low volume complications during the three year period at two of the hospitals. At both of these hospitals, aggregate complication rates also declined. At these hospitals, the differences between actual complication rates and severity adjusted complication rates were also reduced.At the third hospital, specific and aggregate complication rates remained the same or increased slightly. Differences between these rates and those of severity adjusted comparison population also remained the same or increased. CONCLUSIONS: Results of the study suggested that, in one community health care system, the progress of reducing complications involved different experiences. At two hospitals with relatively higher rates at the beginning of the study, management by administrative and clinical staff outside quality assurance produced significant reductions in complication rates, while at a hospital with lower rates, management by quality assurance staff had little effect on reducing the rate of PPCs

Explosive growth of facet joint interventions in the medicare population in the United States: a comparative evaluation of 1997, 2002, and 2006 data

<p>Abstract</p> <p>Background</p> <p>The Office of Inspector General of the Department of Health and Human Services (OIG-DHHS) issued a report which showed explosive growth and also raised questions of lack of medical necessity and/or indications for facet joint injection services in 2006.</p> <p>The purpose of the study was to determine trends of frequency and cost of facet joint interventions in managing spinal pain.</p> <p>Methods</p> <p>This analysis was performed to determine trends of frequency and cost of facet joint</p> <p>Interventions in managing spinal pain, utilizing the annual 5% national sample of the Centers for</p> <p>Medicare and Medicaid Services (CMS) for 1997, 2002, and 2006.</p> <p>Outcome measures included overall characteristics of Medicare beneficiaries receiving facet joint interventions, utilization of facet joint interventions by place of service, by specialty, reimbursement characteristics, and other variables.</p> <p>Results</p> <p>From 1997 to 2006, the number of patients receiving facet joint interventions per 100,000</p> <p>Medicare population increased 386%, facet joint visits increased 446%, and facet joint interventions increased 543%. The increases were higher in patients aged less than 65 years compared to those 65 or older with patients increasing 504% vs. 355%, visits increasing 587% vs. 404%, and services increasing 683% vs. 498%.</p> <p>Total expenditures for facet joint interventions in the Medicare population increased from over $229 million in 2002 to over$511 million in 2006, with an overall increase of 123%. In 2006, there was a 26.8-fold difference in utilization of facet joint intervention services in Florida compared to the state with the lowest utilization - Hawaii.</p> <p>There was an annual increase of 277.3% in the utilization of facet joint interventions by general physicians, whereas a 99.5% annual increase was seen for nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) from 2002 to 2006. Further, in Florida, 47% of facet joint interventions were performed by general physicians.</p> <p>Conclusions</p> <p>The reported explosive growth of facet joint interventions in managing spinal pain in certain regions and by certain specialties may result in increased regulations and scrutiny with reduced access.</p

Resource utilization and costs before and after total joint arthroplasty

<p>Abstract</p> <p>Background</p> <p>The purpose of this study was to compare pre- and post-surgical healthcare costs in commercially insured total joint arthroplasty (TJA) patients with osteoarthritis (OA) in the United States (U.S.).</p> <p>Methods</p> <p>Using a large healthcare claims database, we identified patients over age 39 with hip or knee OA who underwent unilateral primary TJA (hip or knee) between 1/1/2006 and 9/30/2007. Utilization of healthcare services and costs were aggregated into three periods: 12 months "pre-surgery," 91 days "peri-operative," and 3 to 15 month "follow-up," Mean total pre-surgery costs were compared with follow-up costs using Wilcoxon signed-rank test.</p> <p>Results</p> <p>14,912 patients met inclusion criteria for the study. The mean total number of outpatient visits declined from pre-surgery to follow-up (18.0 visits vs 17.1), while the percentage of patients hospitalized increased (from 7.5% to 9.8%) (both <it>p </it>< 0.01). Mean total costs during the follow-up period were 18% higher than during pre-surgery ($11,043 vs.$9,632, <it>p </it>< 0.01), largely due to an increase in the costs of inpatient care associated with hospital readmissions ($3,300 vs.$1,817, p < 0.01). Pharmacotherapy costs were similar for both periods ($2013 [follow-up] vs.$1922 [pre-surgery], p = 0.33); outpatient care costs were slightly lower in the follow-up period ($4338 vs.$4571, <it>p </it>< 0.01). Mean total costs for the peri-operative period were $36,553.</p> <p>Conclusions</p> <p>Mean total utilization of outpatient healthcare services declined slightly in the first year following TJA (exclusive of the peri-operative period), while mean total healthcare costs increased during the same time period, largely due to increased costs associated with hospital readmissions. Further study is necessary to determine whether healthcare costs decrease in subsequent years.</p

A prospective study of rural drinking water quality and acute gastrointestinal illness

BACKGROUND: This study examined the relationship between the bacteriological contamination of drinking water from private wells and acute gastrointestinal illness (AGII), using current government standards for safe drinking water. METHODS: A prospective cohort study was conducted using 235 households (647 individuals) randomly selected from four rural hamlets. Data were collected by means of a self-administered questionnaire, a self-report diary of symptoms and two drinking water samples. RESULTS: Twenty percent of households sampled, had indicator bacteria (total coliform or Escherichia coli (E. coli)) above the current Canadian and United States standards for safe drinking water. No statistically significant associations between indicator bacteria and AGII were observed. The odds ratio (OR) for individuals exposed to E. coli above the current standards was 1.52 (95% confidence interval (CI), 0.33–6.92), compared to individuals with levels below current standards. The odds ratio estimate for individuals exposed to total coliforms above the current standards was 0.39 (95% CI, 0.10–1.50). CONCLUSIONS: This study observed a high prevalence of bacteriological contamination of private wells in the rural hamlets studied. Individual exposure to contaminated water defined by current standards may be associated with an increased risk of AGII

A framework for monitoring the safety of water services: from measurements to security

The sustainable developments goals (SDGs) introduced monitoring of drinking water quality to the international development agenda. At present, Escherichia coli are the primary measure by which we evaluate the safety of drinking water from an infectious disease perspective. Here, we propose and apply a framework to reflect on the purposes of and approaches to monitoring drinking water safety. To deliver SDG 6.1, universal access to safe drinking water, a new approach to monitoring is needed. At present, we rely heavily on single measures of E. coli contamination to meet a normative definition of safety. Achieving and sustaining universal access to safe drinking water will require monitoring that can inform decision making on whether services are managed to ensure safety and security of access