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Critical Reviews in Microbiology Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t713400901 Microbial Agents Associated with Waterborne Diseases H. Leclerc ab; L. Schwartzbrod c; E. Dei-Cas ab a Faculté de Médecine de Lille, France. b Institut Pasteur de Lille, France. c Faculté de Pharmacie de Nancy, France.

Online Publication Date: 01 October 2002 To cite this Article: Leclerc, H., Schwartzbrod, L. and Dei-Cas, E. (2002) 'Microbial Agents Associated with Waterborne Diseases', Critical Reviews in Microbiology, 28:4, 371 - 409 To link to this article: DOI: 10.1080/1040-840291046768 URL: http://dx.doi.org/10.1080/1040-840291046768

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Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article maybe used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material. Downloaded By: [University of Florida] At: 16:15 31 December 2007 onymously with “infection”, which may be may which “infection”, with onymously Likewise, “disease” should not be used syn- water. of ingestion the from develop all not because infections, water-associated of sis analy- theoretical a attempting when culties diffi- poses and simplistic too is however, passing all infections arising from water use, encom- term generic a as “waterborne” of use The waterborne. primarily is water ing drink- for which disease, of occurrence the tradi- tional epidemiological investigation relies because on water drinking with ciated reports of outbreaks or cases of disease asso- for justified is “disease” and “waterborne” agent. infectious the of carrier the passive as acts water and water contaminated of ingestion the through transmitted those orsodne o Poesr . elr, aut d Mdcn d Lle Pl rcece 1 lc de Place 1 recherche, Pôle – Lille de Médecine de Faculté Leclerc, H. Professor to: Correspondence * 3 1 Leclerc, H. Diseases Waterborne with Associated Agents Microbial © 2002byCRCPressLLC 1040-841X/02/$.50 bite near water). in/ (breed vectors insect water-related and host(s); aquatic intermediate on (dependent water-based surface); body and (intestinal waterborne (classic and other); water washed water transmission of infectious agents were for defined categories The them. control or prevent to required technologies gineering en- the to regard with “diseases” infectious initially devised for classifying water-related INTRODUCTION I. Institut Pasteur de Lille, France Lille, de Pasteur Institut France, Lille, de Médecine de Faculté Verdun, 59045 Lille Cedex, France (e-mail: [email protected]) (e-mail: France Cedex, Lille 59045 Verdun, h ue f prtv wrs uh as such words operative of use The or pdmooia ctgre were categories epidemiological Four 1,3 L. Schwartzbrod, L. 1,2,3 Waterborne diseases are 2 and E. Dei-Cas E. and 2 Faculté de Pharmacie de Nancy, France; Nancy, de Pharmacie de Faculté Critical ReviewsinMicrobiology, rtza ptoes xrtd n ee are feces in excreted pathogens protozoan AGENTS ETIOLOGIC AND DISEASES WATERBORNE II. associated. monly epidemiology, and the microbial agents com- their diseases, waterborne about knowledge preferred. is “disease” of instead “infection” of use the discussion, general and clarification of purposes the for fore, pathogenic agents released from of infected carriers). There- levels greater with nation son, food, or water spread (through contami- epidemic to occur from direct person-to-per- an for potential the with situation endemic an in result could individuals susceptible of seeding This infections. asymptomatic duce pro- route water the by levels low in spread many of the bacteria and viruses that may be its However, in unimportant. water is of epidemiology role the then agent patho- genic a with infection water-related a of result end the not is “disease” if that argued be could It identified). was agent causal the “disease”, a therefore and syndrome observable (clinically symptomatic or sion) either asymptomatic (without clinical expres- wd vrey f atra, ia, and viral, bacterial, of variety wide A This review attempts to describe present 1,3 28(4):371–409 (2002)

when 371 Downloaded By: [University of Florida] At: 16:15 31 December 2007 .Te eonzd aebre bacterial waterborne recognized The 3. .Etrc rtza uh as such protozoa Enteric 2. Viruses may only remain static in num- 1. pathogens. of classes different transmitted. excreted with feces and thus potentially water are that protozoa or viruses, bacteria, some for only determined been has dose infective influencing the infective dose. The minimum for multiplication in the ability environment are factors pathogen and power) fectious in- actual of acquisition and excretion gen pathogen survival, latency(theperiodbetweenpatho- to addition In individuals. tible suscep- in infection establishing for quired re- as dose the and water in such survival pathogen factors on depends agents genic patho- by infection of spread cases. Waterborne many in unknown remains tozoa, pro- and viruses for higher usually is which data, dose infective and survival, latency, although the potential for this, predicted from infections, waterborne initiating of capable 372 Therefore, it is important to distinguish to important is it Therefore, ei, including teria, bacteria. The persistence of enteric bac- include pathogens susceptibility. strain virulence humans is highly variable in terms of the The infective dose of waters. receiving the in multiply they cannot viruses, Like treatment. water in infectants and antiseptics commonly used the aquatic environment and to most dis- Cryptosporidium units. infectious ten to one of range the in typically low, is cells. The infective dose of these agents living susceptible of outside multiply indeed, cannot, they waters; receiving ber ordieoff.Theycannotgrowinthe ous parameters, but especially being a being especially but parameters, ous vari- on depends environment aquatic gella spp., and spp., 4 and probably of the host Escherichia coli, Escherichia r hgl rssat in resistant highly are Salmonella

enteric and aquatic and enteric Cryptosporidium Giardia spp., in the in and Shi- in ass f mortality. of causes that up to 70% of diarrhea illness could oc- could illness diarrhea of 70% to up that waterborne. In 1997 diarrhea commonly less much but associated, water are which enteritis, and diarrhea to nually an- ascribed deaths of millions the for sible respon- are care, medical of lack and tion quantity or availability, along with malnutri- in deficiencies These water. drinking in ties impuri- from than uses hygienic household and personal for sufficient quantities in ter wa- of availability of lack sheer from result deaths and illnesses more countries, wide oped or developing countries. In many world- The situation is markedly different in devel- countries. developed in transmission borne water- with associated principally diseases the of characteristics and infection of rates ogy of waterborne diseases, that is to say the ass f obdt (4.10 morbidity of of assessment causes report’s WHO the in first This discussionconcernstheepidemiol- to 10 to orrhagic Campylobacter including species, enteric bacteria are in the range of 10 of range the in are bacteria enteric avium as such mycobacteria ease and probably with nontuberculous the etiologic agent of Legionnaires’ dis- cifically with spe- aerosols, of inhalation direct the through is transmission water-related of mode in additional An water. drinking proliferate and survive both can that organisms aquatic indigenous are aeruginosa, spp., rial infectious agents such as bacte- Other water. fresh in grow can conditions, thereisevidencethatsome usually assumed to exist under starving are bacteria enteric Although perature. tem- and present nutrients of function 8 cells but much lower with some with lower much but cells Aeromonas . The infectious dose of historic of dose infectious The . E. coli E. and Legionella pneumophila 5,6 p. ad enterohem- and spp., O157:H7. Mycobacterium avium t a b suggested be can It spp., Shigella 9 Mycobacterium ad it in sixth and )

disease ranked Pseudomonas Legionella spp., 7 , Downloaded By: [University of Florida] At: 16:15 31 December 2007 logical course of waterborne disease in the in disease waterborne of course logical Epidemio- monitoring. microbial and gies, technolo- treatment regulations, programs, mate the effects and adequacy of public health analyzed by Craun by analyzed were water drinking with associated breaks out- on 1920 to back dating statistics tional and private or individual water systems. Na- nity water systems, noncommunity systems, tics. Water systems are classified as commu- statis- the in included is incident the before sons must show the same clinical symptoms Protection Agency (EPA). Two or more Environmental per- the and (CDC) Prevention United the States by the Center for Disease Control for and reported those are disease by water. contaminated be could outbreaks for responsible food that stated be also should It origin. water polluted from result could cur by contaminated food, and therefore 30% The most complete data on waterborne on data complete most The FIGURE 1. FIGURE Etiology of waterborne outbreaks, United States of America, 1920–1996. America, of States United outbreaks, waterborne of Etiology 2,7,8 in an attempt to esti- to attempt an in and of shigellosis, emergence of continuance campylobacteriosis with 1998 through 1920 clear-cut a by break of bacterial diseases during the period marked is 1) (Figure U.S. eot ad eiw hv be published recently in the been U.S. on the concern. have reviews and reports ubek o wtrrltd netos This infections. water-related of of outbreaks Europe in occurrence the on available agents in the US in 1980 to 1990s. Norwalk of detection the by supported was and suspected been has adenoviruses) and viral a etiology outbreaks, these of many in ever, mined in almost half of the outbreaks. How- deter- not was (AGI) gastroenteritis acute 1920. During the last decade, the etiology of in began keeping record since 1993 in kee Milwau- in incident documented largest the including 1970s, from outbreaks protozoan of incidence extended by correlatively and Unfortunately, there is a paucity of data of paucity a is there Unfortunately, . coli E.

(Norwalk agents, human rotaviruses, 17H hmrhgc colitis, hemorrhagic O157:H7 6,10,11,12,13,14 3,9 Several 373 Downloaded By: [University of Florida] At: 16:15 31 December 2007 ported outbreaks. Craun re- than prevalent more far is disease borne in the U.S. have declined dramatically from dramatically declined have U.S. the in Shigella – Salmonella A. ENTEROPATHOGENS BACTERIAL III. disease. infectious waterborne to million 8 attributable deaths 1200 and illness of cases to 7 be could U.S. the in dence ubr f reports of number growing A incomplete. are reports outbreak world-wide. disease waterborne of review comprehensive most the conducted the U.K. including published, been have ease dis- waterborne European on reports Some miological investigations of such outbreaks. epide- with associated problems the to uted attrib- likely more is it but Europe, in rare are outbreaks water-related because be may 374 cording to Morris and Levin, and Morris to cording are detected, investigated, occurring outbreaks waterborne of one-tenth, even or one-third, to one-half Waterborne outbreaks of bacterial origin t s eeal are ta waterborne that agreed generally is It 15 and Nordic countries, outbreaks (USA, 1930–1990). (USA, outbreaks 2. FIGURE 6,8,18 Comparison of typhoid fever and shigellosis occurring in the waterborne the in occurring shigellosis and fever typhoid of Comparison niae ht water- that indicate 7,8 suggests that only

and reported. Ac- 16 while Hunter 18 annual inci- annual

in the U.S. the in I , typhoid fever outbreaks, fever typhoid , 17 fever from 1920 to 1945 to 1950. to 1945 to 1920 from fever typhoid to attributed entirely almost were infections waterborne from Deaths 1900. tion treatments, introduced between 1890 and wide- the spread applicationofdisinfectingandfiltra- of result a as 1970 since rarely seen is which fever, applies typhoid to particularly This 1970. to 1960 through 1920 f lns cn rbby e xlie b a similar change in incidence by of explained be probably can illness of gella in change The previously. dominated replacing agent, bacterial sonnei gella 1961, Since 2). (Figure increased have shigellosis of those whereas years, the over stable relatively been has salmonellosis of other hand, the number of reported outbreaks f atra gsretrts n h commu- the in gastroenteritis bacterial of that three outbreaks 1991 to 1996) 1990, to 1981 outbreaks 10 1980, to 1971 jejuni lobacter Campylobacter B. patients. in types Campylobacter Waterborne outbreaks caused by species causing the majority of cases of majority the causing species has become the most prevalent most the become has G in the U.S. (three outbreaks (three U.S. the in , shigellosis outbreaks. shigellosis , is now a leading cause leading a now is . flexneri S. 2,8 Shigella demonstrate 8 On the On Campy- sero- that Shi- Shi- Downloaded By: [University of Florida] At: 16:15 31 December 2007 in of tion vehicle for campylobacter transmission. In transmission. campylobacter for vehicle a be may groundwater that theory the ports sion of infection. there was evidence for waterborne transmis- 26 outbreaks between 1992 to 1995 in which observed Centre Surveillance Disease cable Communi- the Wales, and England in tem introduction of an improved surveillance sys- the Following death. in resulting sometimes sequel serious to leading often disease, severe a is campylobacteriosis Human U.K. the and U.S. the in diarrhea of cause terial rhea; it is the most frequently identified bac- nella as commonly as isolated is It nity. susceptible tochlorination. are they because water treated in however, found, were bacteria Campylobacter-type feces. bird with contaminated be may that water follow the consumption of untreated surface typically outbreaks Waterborne birds. wild mote areas, where contamination stems from re- in even campylobacters, contain waters surface all Virtually pollution. vironmental en- of reservoir large a for account poultry, as such production, food for used animals enteritis Campylobacter unl fo smls f rs water. fresh of samples from quently water. drinking the of source the was which of some ters, wa- lake and river in studied was lobacters humans. to transmission of vehicle primary the be to poultry causing thus tract, ticularly ill. persons hundred nearly caused Finland, a waterborne epidemic in a hospital Canada with presumed waterborne outbreaks; waterborne presumed with associated were they recently, More 1970s. late the since pathogens human important as known been have campylobacters tries, 22 The occurrence of thermophilic campy- thermophilic of occurrence The Campylobacter Other outbreaks have been described in and 27 23,24 . jejuni C.

well adapted to the avian intestinal avian the to adapted well Shigella and in New Zealand. New in and C. jejuni C. 19 In Nordic–European coun- rm groundwater from from patients with diar- with patients from species appear to be par- was recovered fre- recovered was s zooi and zoonosis a is 31 Thefirstisola-

25 o become to Salmo- 32 20,21 sup- 28,29,30

and in 26 producing produce VT became known as the Verotoxin- appeared elucidated by Cappelier et al. virulence and pathogenicity retaining for power their be u noncultivable but able vi- of existence The conditions. anaerobic and nutrient with decreasing temperature and by Verotoxin (VT), and the group of line cell). The kidney toxin was appropriately monkey named green fibroblastic (a cells Vero for cytotoxic toxin of production the to part in attributed been has pathogenicity (hemolytic uremic syndrome) in humans. failure Its renal and colitis) diarrhea (hemorrhagic bloody of cause important an as hemolytic ureic syndrome. been associated with hemorrhagic colitis and other verotoxin-producing C. mans. hu- in infections of significance clinical the Arcobacter butzleri Arcobacter with associated were however, rhea, nized as a pathogen in 1982, uvvl times. survival the influence biofilms and nutrient, ditions, as temperature, oxygenation, anaerobic con- such factors experiments, microcosm water be suspected. be lobacter aerotolerant as designated viously Talibart et al. et Talibart including cause of VTEC-related human illness. VTEC, however, is recognized as the most common borne, particularly from contaminated ground food- often is O157 VTEC of transmission The ruminants. of stomachs through clearly pass can they and cattle, with sociated

the presence of autochthonous microflora Escherichia coli coli Escherichia shrci coli Escherichia The spread of ) via the drinking water path must path water drinking the via ) 35,36,37 E. coli E. E. coli E. 40,41 39 was a debatable point until it 33,34 O157:H7, are strongly as- strongly are O157:H7, Some cases of acute diar- acute of cases Some Arcobacter (VTEC). uvvl a enhanced was Survival ; 42 17H, is recog- first O157:H7, little is known about known is little

O157:H7 aplbce, and campylobacter, 44 E. coli

44 E. coli 43 organisms (pre- Subsequently, is now known strains have E. coli O157:H7, Campy- 38 that and 375 Downloaded By: [University of Florida] At: 16:15 31 December 2007 isms or less. or isms organ- hundred some approximately dose, jejuni C. bacterial indicators. bacterial as chlorination to susceptible as is O157 infection is relatively rare because VTEC waterborne however, O157, VTEC with environment of contamination large for potential the Despite supplies. municipal ated with recreational waters, private and associ- O157 VTEC of outbreaks lished Doyle, 1998). Doyle, sociated with swimming in lakes (Wang and as- outbreaks by suggested as environment, ticularly adapted for surviving in the aquatic par- is O157 VTEC infection. O157 VTEC waterborne of therefore and tamination, however, are a potential source of fecal con- areas, catchment water in grazing animals re- wild and Farmed infection. human in also sulted has animals farmed with contact and person-to-person, or milk, raw or beef 376 or Community. souri by unchlorinated municipal water outbreak in the Mis- large unusually an by demonstrated clearly first was infection tures. tempera- cold at especially days, many for elevated dose. elevated species may require a 10 to 100 times more other the while dysentery, clinical cause to virulent most the of organisms 100 to 10 as few As disease. trigger may that organisms of lum inocu- low the is feature striking most The recently. concern of source a become have O157:H7, elucidated the mechanisms by which prdc ae ad n ubek o ill- ness. Chalmers of et al. outbreaks in and cases sporadic in described been has O157 VTEC borne by o oe hn fw ude bacte- ria. hundred few a than more no ably prob- low, also is campylobacteriosis ger 50,51 The waterborne route of VTEC O157 VTEC of route waterborne The pdmooia ivsiain have investigations Epidemiological

E. coli E. S. dysenteriae , appears to have a low infectious low a have to appears , Shigella 52 45,46 O157:H7, like O157:H7, 49 The dose required to trig- to required dose The It is capable of surviving of capable is It spp., and campylobacters 47 48 48 ic te, water- then, Since type 1 are sufficient have analyzed pub- Shigella E. coli and and . aldovae Y. Y. intermedia Y. of tal strains, including nonpathogenic serotypes tems, they are often referred to environmen- lated from terrestrial and fresh water ecosys- enterocolitica Y. n te U.S. the and with human infectionsinEurope,Japan,Canada, associated ones frequently most the O:27 and O:8 of differentiated fromserotypesO:3,O:9,O:5, be should therefore strains Environmental types. various of supplies water including environment, the from commonly isolated concerning developing countries, where cholerae tde fo Norway from studies ever, are scarce (Schieman, 1990) (Schieman, scarce are ever, data concerning waterborne yersiniosis, how- Epidemiological water. drinking to hazard major a constitute could and waters fresh in multiply can hence and psychrotrophic, this outbreak uncertain. outbreak this tified as nonpathogenic, leaving the cause of iden- later were sources water from isolated Zealand o a ag nme o “tpcl or “atypical” of number large a for ever, waterborne yersiniosis, be to suggested was 1977 in resort ski tana large outbreak of intestinal illness at a Mon- volve only a small number of individuals. A D. E. mon in the examined water supplies. water examined the in mon com- relatively however, were, strains tal in these area. these in Y. enterocolitica Y. Vibrio cholerae Vibrio Yersinia enterocolitica Yersinia Bacteria of the genus hlr cue b toxigenic by caused Cholera Y. enterocolitica Y. Y. rohdei Y. Y. enterocolitica Y. 57 s mjr ulc elh problem health public major a is em o eosrt ta, how- that, demonstrate to seem , . bercovieri Y. . , 58 Y. kristensenii Y. 53 These aquatic environmen- aquatic These Y. enterocolitica lk sris Uuly iso- Usually strains. -like hs ptoye are pathotypes These and the related species related the and became the repository the became could be waterborne be could 54 55,56 17 but the many strains Yersinia Three prospective Three , n fo New from and . frederiksenii Y. , Y. mollaretii, Y. , which are have been 53 and in- and Vibrio 59,60,61 out- , Downloaded By: [University of Florida] At: 16:15 31 December 2007 onstrated epidemic potential in the 1960s. hip o rw ytr fo te uf of Gulf the from oysters raw or shrimp, or crabs undercooked of consumption the with associated were cases to Most 1970 1990s. in U.S. the in reported was era 1992, late In America. South and Africa East and Asia, whereas the seventh pandemic Southeast reached West and South to confined six pandemics, cholera remained principally caused by caused pandemics of cholera occurred; all these were genes. virulence two these lack serogroups 95%) the strains of non-O1 non-O-139 (more than contrast, In production. CT with regulated toxin- coordinately is that (TCP) pilus coregulated as known factor colonization and (more than 95%) produce cholera toxin (CT) strains belonging to serogroups The O1 and O139 genes. associated virulence to related This sharp distinction between serogroups is serogroups O nized recog- currently 193 the Among poor sanitation. and poverty with associated are and breaks ei o coey eae t sc a such clone. to related closely or demic arisen from a lineage that was already epi- likely were clones cholera new that cates indi- clones epidemic O37 and O139 O1, The close evolutionary relationships among diarrhea. sporadic cause can O-139, non non-O1, as to referred usually serogroups other The cholera. of epidemics with ated associ- been have O139 and O1 serogroups gions. cholerae V. of coexistence or alternation temporal these countries from 1992 to 2000 revealed countries. through India, Bangladesh, and neighboring cholera of epidemics explosive caused Bengal) O139 as referred (now serogroup rm 87 o 94 svn distinct seven 1994, to 1817 From ytmtc uvilne f hlr in cholera of surveillance Systematic 63,64,65 63,66,67,68 cu i a eua saoa pattern seasonal regular a in occur . cholerae V. V. cholerae V. A clone of serogroup O37 dem- O1 and O139 in different re- different in O139 and O1 An endemic focus of chol- of focus endemic An eogn t a non-O1 a to belonging f . cholerae V. of O1. During the first the During O1. only , 62 66 sociation of sociation as- close the by suggested is ecology water of importance The areas. estuarine and ine many aquatic environments such as in river- in microflora the of member autochtonous .The major pathogenic gene in toxinogenic 2. fetd cnend b coea n the 1990s. in cholera by (concerned) affected Mexico. tamination of foods. of tamination con- of source the is water instances many food also plays an essential role, although in water- the with interacting population and .Te tt o a autc eevi of reservoir aquatic an of state The 1. that suggest data Recent cholera. of outbreaks appearance epidemic seasonal explain to unknown remain pects . cholerae V. Vibrio but nonculturable form (VNC) viable a to converted be can vibrios the conditions stress under that lated tious bacteria. infec- tious live to back reverted be can yoei conversion. by lysogenic strains non-O139 and non-O1 to capable of being propagated horizontally are that island) pathogenicity TCP and element genetic (CTX regions mosomic V. cholerae and estuarine areas, is also relevant. water fresh in strains, O139 and O1 than O139 strains non are more commonly and detected O1 non that Likewise, cance. of strains environmental in genes virulence critical of expression and occurrence the V. cholerae V. of ecology the on data new These genes. virulence of reservoir environmental hkaot e al. et Chakraborty of the ecosystem. component complete a form to also pable not only to survive in water but cholerae V. 70,71,72,73 V. cholerae 69 In Europe, several countries were features can be involved: be can features V. cholerae V. s o rcgie a an as recognized now is are clustered in several chro- appear to be of great signifi- great of be to appear 1 r 19 en ca- being O139 or O1 that appear to constitute an 74 V. cholerae Many ecological as- ecological Many 62 75 with surface water surface with ae demonstrated have It has been postu- 63 oe recently, More strains and 76,77,78 63,79,80 that 377 Downloaded By: [University of Florida] At: 16:15 31 December 2007 is a species of considerable versatility and a and versatility considerable of species a is dantly in the purest of waters. matter content, because it can develop abun- organic the to linked directly not is water in ters that receive polluted effluents. Its growth A. avium Mycobacterium nas aeruginosa, Aeromonas, Legionella, portant organisms to consider are im- most The disputed. is water drinking in occurrence their about concern but humans, in pathogens opportunistic are They ents. nutri- organic of levels low with even water in multiply to able are pathogens other bacterial nonculturable, but viable remain or survive and environment aquatic the to cess SUPPLIES WATER IN GROW THAT PATHOGENS BACTERIAL PUTATIVE IV. 378 barriers and monitoring by using indicators. multiple by diseases enteric of management of concepts basic the substantiate clusions con- These reach. within usually is ciencies defi- such of control outbreaks; waterborne distribution system were the major or causes of procedures disinfecting inadequate ter, wa- ground or surface untreated that lished cessing deficiencies. Thus, it has been estab- pro- with surveillance waterborne-disease the CDCandEPAmakeeffortstorelate waters Its presence is constant and abundant in waste lettuces and onions, cucumbers, radishes, tomatoes, as such vegetables, numerous from isolated ters, soil, and plants. This bacterium has been wa- fresh of inhabitant microorganism, tous Pseudomonas aeruginosa Pseudomonas Like fecal pathogens that may have ac- have may that pathogens fecal Like n ubek wt a atra etiology, bacterial a with outbreaks In Pseudomonas aeruginosa Pseudomonas 82,83 81 at rates capable of reaching 10 reaching of capable rates at and consequently in surface wa- surface in consequently and complex. is an ubiqui- an is P. aeruginosa Pseudomo- and 3 /g. 6 children. and infants in diarrhea of agent causative and pathogen enteric an as bacterium this ognized rec- have publications later many 1894, Since nicity of this species was sometimes surmized. enteropathoge- the enterotoxins, producing of s xone b Hrao n Edberg and Hardalo by expounded As adults. and children both affected that illness of the organism from the stool. the from organism the of nization, butonlytoabriefperiodofrecovery P. aeruginosa 1918 in Dold by earlier described was septicaemia logical or haematological problems. haematological or logical is, that those infants, who lack identified underlying immuno- healthy in occurs rarely sis P. aeruginosa acquired Community etiology. protozoan or viral a precluding of means adequate were of these “infections” was diagnosed before there each Moreover, corrected. are conditions tary sani- environmental the once ceases quickly by children of colonization s pbi hat rs. However, risk. health aeruginosa P. public a as presence of tae ta te neto o u t 10 to up of ingestion the that strated other hand, ie h si ad uos ebae of membranes patients. mucous and skin the nize ubiquitous bacteria has been this selected to colo- why explains antibiotics to resistance to 20% of nosocomial infections. Its extreme ronment; it seems likely to be the cause of 10 envi- hospital the in known well pathogen, warm- blooded animals.Inmanitisanopportunist and insects, plants, of variety a in significant pathogen that can cause infection niques. better of hygienic control measures result and diagnostic tech- as possibly decades, recent There have beennosignificantoutbreaksreportedin children. and adults hospitalized and the gastrointestinal tract in immunocompromised n h ps, Hoadley past, the In As some 88 as“Shangaifever”,aprolongedfebrile 90 84,85,86,87 oevr a 99 study 1969 a Moreover, P. aeruginosa P. aeruginosa P. aeruginosa gastrointestinal disease with sep- did not lead to infection or colo- is predominantly an environ- an predominantly is Enteric disease associated with can be a colonizer of 92 strains are capable indrinkingwater osdrd the considered . aeruginosa P. 91 90 demon- On the On 6 viable 89 the Downloaded By: [University of Florida] At: 16:15 31 December 2007 and Edberg Hardalo and insignificant, is water drinking rily a nosocomial pathogen. prima- is bacterium this hand, other the On benefits. protection health public yield not B. avoided. with in hospitals supplies water hosts vulnerable highly for an infection with infection an for risk at are hosts specific that evidence dant ua dare eegd rm tde of al. et Morgan studies from emerged diarrhea human Aeromonas that suggesting diarrhea, without persons as diarrhea with patients of feces the from Aeromonas from originating lation popu- general the to risk The organism. the with contact continuous in are also surfaces body our while vegetables, raw with larly particu- food, our with ingested are species the of numbers substantial Daily, surfaces. relatively high numbers in food and on moist lifestyles, temporary con- of consequence a As reservoir. ideal an water surface fresh and organism mental cally involved in diarrhea illness. that assertion the to credence lend to tend data miological for and patho- be with that to similar situation a genic, to likely are strains some only that consider and cautious more are authors hs netgto fie t establish to failed investigation this used, were doses challenge high that spite oeg dvc installation. device foreign to subject those and burns, severe fibrosis, cystic neutropenia, deep with patients ing argument against the role of role the against argument striking most The traveler”. “fellow genic Aeromonas P. aeruginosa P. Many experimental, clinical, and epide- and clinical, experimental, Many Y. enterocolitica Y. 89 would as a rule a as would times many as isolated be may think that attempts at guideline 101 Aeromonas with human volunteers; de- volunteers; human with . aeruginosa P. in drinking water would water drinking in . P. P. aeruginosa P. 100

Beyond any doubt, any Beyond aeruginosa . aeruginosa P. a b etiologi- be may 93 94,95,96

be a nonpatho- a be Aeromonas There is abun- hud be should 97,98,99 o these For , includ- , reaches E. coli E. Some Aero- in in aeromonads range from 10 mesophilic of the concentration The of organism. habitat natural the represented but origin, fecal human from not were strains available most waters; environmental with ea clfr test. the coliform in fecal positive was sample the that cated age. sew- in coliforms outgrow organisms, why reason Aeromonas the probably is That ter. the colonization by aeromonads in wastewa- perature is an important factor for enhancing ae ic be cnimd y many teams. by confirmed been since have strain or pathovar related. pathovar be or strain may aeromonads of pathogenicity the monas ie n uefca gon water. ground superficial in like siphons, sinks, and drainage systems. wastewater industrial Aeromonads readily multiply in domestic or of strains contained indeed “fecal-coliforms” of drinking water samples found positive for Since 1962, we have demonstrated that 30% sewage to 10 to 10 to 10 to sewage bution system has been studied by typing. by studied been has system bution distri- from isolated those and humans from isolated aeromonads between relationship epidemiological The systems. distribution of Aeromonas number mean with correlated closely Aeromonas onstrated. dem- been had adhesins and/or enterotoxins as an enteric pathogen, because production of role its of question the raised water drinking uohoos lgtohc bacteria. oligotrophic autochtonous nutrient-poor waters in comparison with other in poorly survive aeromonads that appears it hand, other the On temperature. and load organic to related closely is rate their water, surface fresh and wastewater in residents Aeromonas Aeromonas The frequent presence of presence frequent The 103,106,107 103,110,111 spp.asanenteropathogen.However, 74,112,113 spp.-associated gastroenteritis was spp., which are psychrotrophic are which spp., Hence, aeromonads are natural are aeromonads Hence, spp. in water samples within the within samples water in spp. that would have falsely indi- falsely have would that p. r wdl associated widely are spp. Burke 3 /ml in clean river water river clean in /ml 109

and are also found in found also are and hs observations These 110 6 to 10 bevd that observed Aeromonas 8 /ml in crude 102,103,104,105 103 Tem- 103,108 3 in 114 7 9 Downloaded By: [University of Florida] At: 16:15 31 December 2007 water standards. water drinking meet that supplies water of and tats habi- aquatic natural of numbers, low in ally aerosols. contaminated of inhalation of result the is Infection symptoms. constitutional mild self-limiting nonpneumonic diseaseconsistingoffeverand a fever, Pontiac and monia Legionnaires’ disease, an acute purulent pneu- or legionellosis namely, disease, of forms two ment L. pneumophila of replication intracellular subsequent and sion Inva- environment. the in legionellae for fiers” other protozoa may be natural hosts and “ampli- C. water. from isolated frequently is rium bacte- this although reported, been ever have outbreaks of diarrhea defined illness due to clearly no pathogens, waterborne other to contrast in water, drinking with ship relation- epidemiological the to regard With gastroenteritis. with patients from isolated those to unrelated were supply water public the from isolated aeromonads the that sively conclu- demonstrated investigations These 380 man disease. man hu- to related frequently most is 1 serogroup species, ings. build- or hotels, hospitals, of systems bution are able to colonize all parts of internal distri- Then, “amplifiers”. bacterial as serve function, heat-exchanging their of tanks, cooling systems, and towers, growth. and survival influence significantly one, tant tors, of which temperature is the most impor- eoos rae i soes ube baths, etc. sinks, bubble showers in created aerosols through persons susceptible infect tially Legionella Legionella The genus Evidence also indicates that indicates also Evidence 120,121,122

should play a major role in the transmis- the in role major a play should 116 mn which among Thus, these bacteria can poten- can bacteria these Thus, Legionella Legionella within protozoa in the environ- is a common inhabitant, usu- inhabitant, common a is 117 A number of abiotic fac- abiotic of number A 118 Therefore, hot water hot Therefore, infections can lead to lead can infections had at least 42 named . pneumophila L. Legionella amoebae Aeromonas Legionella 119 because 115 spp. and . pneumophila L. of power infectious the enhances even growth h lns n tee osiue n infectious an dose. constitute there and lungs the of alveoli the reach may which legionellae, of bae producevesiclesthatcontainhighnumbers some stage after the ingestion of bacteria, amoe- sion ofLegionnaires’disease. elcto wti protozoa. within replication pneumophila L. noncultivable environmental of fectivity in- and viability that shown been has it cently, tion or hyperchlorination. or tion eradica- thermal by time of periods tended ex- during legionellae with reservoirs and systems supply water of contamination the D. Nontuberculosis Mycobacteria Nontuberculosis D. etc. diabetics, as people, elderly such disease, respiratory against tance be introduced for people with reduced resis- sures of surveillance and intervention should sons is yet impossible. However, special mea- per- debilitated vs. robust exposed for risks relative Quantifying whirlpools. and swimming pools, in spas, public in hospitals, of systems supply water in is, that recognized, Legionella control to introduced be should strategies ( view re- benchmark a In mycobacteria. “atypical” than M. other “mycobacteria or (NTMs) ria” mycobacte- “nontuberculosis and animal, and man for pathogenic species of composed is ant e sesd n rmis pn to open speculation. remains and assessed be cannot to exposure following fection nld the include cause disease. The most common to among these able were mycobacteria nontuberculosis M. tuberculosis tuberculosis”, include the formerly called formerly the include tuberculosis”, It appears that it is impossible to prevent The 131 129 the evidence was summarized that some Mycobacterium tuberculosis at locations where a health risk is 130 yoatru avium Mycobacterium Therefore, risk management risk Therefore, can be restored by intracellular by restored be can o ua-eie cells. human-derived to , M. bovis , and 124 117,123,124,125,126 The risk of in- of risk The 127 M. africanum Intracellular Legionella complex complex 128 Re- At ) Downloaded By: [University of Florida] At: 16:15 31 December 2007 cipally by from either blood or stool commonly and caused prin- more isolated being ganisms or- acid-fast with systemic usually is ease viduals, nontuberculous mycobacterial dis- indi- immunodeficient other and patients AIDS the epidemic in the U.S. and Europe, in AIDS of advent the with However, pools. swimming or aquaria from nating origi- infections skin with associated was hdnts n hlrn and children, in phadenitis lym- cervical of agent causative the ered other reviews paratuberculosis avium designations M. the with species one in placed berculosis, that proposed been has it relatedness, phenetic and homology DNA quences. se- rRNA 16S and homology DNA-DNA on M. intracellulare of composed (MAC) complex, including member of the of member aerosols. via sources environmental from infected transmission, itwassuggestedthatmanis person-to-person of evidence of absence avium, M. and the major pathogens were bacterial disease was primarily pulmonary myco- nontuberculous people, competent AIDS epidemic and the still today in immuno- Before world. the throughout demic epi- AIDS the of emergence the by cally cobacterial disease has been changed radi- which these organisms infect or colonize man. by vehicle the be may water particularly more and environment the that evidence in increase respectively. . avium M. from distinct phenetically and netically However, described. and The concern about nontuberculosis my- . scrofulaceum M. 132 131 and subsp. n te od ien ails be bacillus pigeon wood the and On the other hand, on the basis of basis the on hand, other the On M. avium and 133

M. scrofulaceum M. 135,136,137,138 It should be noted that a “MAIS” . intracellulare M. M. avium M. clearly different species based , . intracellulare M. M. avium M. M. avium avium . Therefore, infections . scrofulaceum M. a be occasionally been has M. avium M. have contributed to an complex. , subsp. . avium M. , . avium M. M. intracellulare was consid- was . marinum M. M. kansasii n i nt a not is and , silvaticum, M. paratu- M. 134 I the In . Several subsp. s ge- is and , , ease in AIDS people is low. dis- mycobacterial nontuberculous of rate the high, is tuberculosis of incidence the other areas of the developing world, where vestigated in AIDS patients. In Africa and in- be to had has exposure of routes and sources of range wider a Thus, tract. tinal possibly occur via the lungs or gastrointes- rd rm ay ie ad rae drinking waters throughout the treated world. and piped many from ered n aerosols. and distributed in the environment: water, soil, dust, teria are free-living saprophytes that are widely and grow in human tissue, nontuberculous bac- Water in Transmission and Mycobacteria Nontuberculous of Occurrence E. onset slow which at stage a reach they before tions infec- other of die patients AIDS ability acids; not fulvic and humic as such biodegradable readily compounds transforming of capable are they coumpound; organic xenobiotic of variety wide a of degradation for responsible be may they that shown been has it (7) metals; polluted metals and may be isolated from water by highly heavy to resistant relatively are they (6) faces; inter- air-water at largely collect and drophobic hy- are they (5) estuaries; and swamps brakish in numbers large in found are and salt of level high a with water in well equally grow they (4) intracellulare M. (3) is, that microaerobically; (2) and 5.5, and 5 between values, pH low at best grow they (1) understanding of their ecological distribution; nontuberculous mycobacteria have provided an water. in grow and survive to able residents but source, another from up picked contaminants not are NTMs In contrast to tuberculous bacteria that live h pyilgcl hrceitc of characteristics physiological The . avium M. 147 (8) their high resistance to disinfection to resistance high their (8) M. avium M. 138,140,141 tan go a 4˚, unlike 45˚C, at grow strains that can grow to only 42˚C; only to grow can that hy ae en recov- been have They disease develops. disease 135,136,142,143,144,145,146 139 In all prob- 381 138 138 Downloaded By: [University of Florida] At: 16:15 31 December 2007 pathogenic mycobacteria, such as for host as environments water in present zoa proto- for role a suggest data experimental eral in i AD ptet, n wtr s the as the of water source and patients, AIDS in tions infec- between relationship a document to may deliver both hot and cold water. cold and hot both deliver may tap common a because source, possible a as it acts water drinking that but excluded be cannot infection, of source the be may ers baths, and whirlpools. public aquaria, and pools swimming waters, tic and treatedwaterssuchasdrinkingdomes- piped in estuaries, and water, as salt water, such fresh waters natural in growth occasional even and survival their favor attributes These systems. water drinking in their persistence to contributes undoubtedly chlorine by 382 documented. been also has access respiratory although waterborne mycobacterial infections. mycobacterial waterborne of problem emerging an to contribute systems water in mycobacteria nontuberculous of lence in the immunodeficient population and the preva- ope bt not but complex the by caused disease of dence in inci- the on effect striking a countries, most had, has epidemic AIDS The fections. than common more demic, uiia systems. municipal colonize once they and have been introduced from persist to mycobacteria rine-resistant buildings, may allow thermotrophic and chlo- office and apartments, hotels, hospitals, as water systems, used hot in many institutions such Recirculating hospitals. in infections source of the nosocomial spread of a is water potable that possibility the ports ooiain f h gsritsia tract, gastrointestinal the of colonization avium M. The study from Aronson et al. et Aronson from study patterns. The identical showing PFGE by ters wa- from and patients from isolates of tion Von Reyn et al. et Reyn Von Before the emergence of the AIDS epi- AIDS the of emergence the Before M. kansasii M. complex is thought to occur from occur to thought is complex 152 M. avium M. Therefore, hot water show- water hot Therefore, . kansasii M. infection were generally were infection 144 135,136,138,141,146,148 M. avium M. 136,142 were among the first the among were complex, examina- complex, neto with Infection M. avium Ide, be- Indeed, . 150 complex in- complex also sup- also . avium M. M. avium Increases 138 153 Sev- . 148,149 151 losis ces. If it is later proved that culosis of transmission the to due is gest four transmission ways: transmission four gest sug- Studies one. only the is niche ecological this whether establish to however, difficult, is the gastric mucus and the gastric epithelium, it that shows in drinking water and shower heads. reports relating the of occurrence of number a been have There Pulmonary. exclusively or disseminated be can AIDS) with those (e.g., patients immunocompetent tract. gastrointestinal the of disease flammatory in- invalidating, chronic, a is which mans, hu- in disease Crohn’s with implicated also that suggested have data Several cattle. in disease Johne’s possible. be may route exposure water the infections, the with like Therefore, V. aerosols). or posure to contaminated water (e.g., drinking ex- through occur also would infection man hu- disease, of bacteria responsible the are led Herman Taylor et al. have disease of distribution geographic and r ati cancer. gastric or disease, ulcer peptic gastritis, chronic develop people infected many harmless, is infection significance. Although in the majority of cases, lori with infected is population world’s the of Half substantiated. be to needs waterborne in i England. in tions infections comparedwith increase in the number of tween 1984 to 1992 there has been a 10-fold HELICOBACTER PYLORI HELICOBACTER , making it a pathogen of potentially great potentially of pathogen a it making , . paratuberculosis M. The assumption that or wood pigeon strains of strains pigeon wood or 138 via water contaminated by cattle fe- cattle by contaminated water via Epidemiologic studies of incidence of studies Epidemiologic H. pylori H. M. paratuberculosis M. 154 159 is well suited to attach to attach to suited well is

lhuh l evidence all Although . kansasii M. Helicobacter pylori 157 M. avium M. M. avium s h aet of agent the is M. kansasii to propose that it M. paratubercu- 160,161,162,163 M. paratuber- M. M. avium M. M. kansasii ies in disease 135,138,155,156 complex complex may be may infec- H. py- H. 158 is Downloaded By: [University of Florida] At: 16:15 31 December 2007 persist up to 20 to 30 days in water in days 30 to 20 to up persist may that form coccoid noncultivable the to Finally, by the gastric-gastric route, the 4. By the gastric-oral way, the typical mo- 3. By the oral-oral route, 2. bacterium, the route, fecal-oral the By 1. and also in food. in also and of capacity survival The chlorine. free by inactivated readily be should organisms the although surface water, bility that tion. Many studies have examined the possi- of occurrence widespread pcfc N ws eetd n sewage, in detected was DNA specific one no cause be- however, involved, be contemporaneously may transmission of modalities ferent oe aa hw that show data more cers, ul- peptic with patients or individuals in- fected of samples feces from PCR by detected for diagnosing for promise new brings SA) (Hp stools in antigen of detection The transmission. oral low groundwater samples tested in the U.S. antibody in the majority of surface and shal- monoclonal by found were bacteria spiring oe n neto with infection in role suggested that drinking water might play some unconfirmed by other works. other by unconfirmed demic vomiting in childhood. in vomiting demic epi- of result a as specifically juice, gastric Studies of the prevalence or seroprevalence The natural route of transmission is by is transmission of route natural The 175,176,177,178 doscopic procedures. doscopic en- by transmitted be might bacterium vomit; contaminated by childhood, in transmission of dality viduals (person to person transmission); indi- other to saliva by transmitted be colonizes dental plaque and saliva, may man; to transmitted be to available becoming sources, ter wa- colonize might feces, by excreted H. pylori 165 togy ugsig fecal-to- suggesting strongly e se per H. pylori H. andwatersupplies, 172 is waterborne. s be o xli the explain to able is . pylori H. . pylori H. infection. H. pylori H. . pylori H. H. pylori 169 173,174 161,162 N cn be can DNA Actively re- Actively , 168 More and More 179 is related is H. pylori hc is which The dif- The H. pylori H. The re- The 165,170,171 166,167,168 , which infec- 170 164 - mission. trans- of mode the as route oral-fecal an port sup- to seem also model murine experimental curd n 95 n ea, ih sewage- with Texas, in 1985 in first occurred The outbreaks. waterborne a of as cause recognized been recently more only parvum ouetd n 95 t se, Colorado. Aspen, at 1965 in documented U.S. over the the last 30 years. The in first outbreak was disease waterborne human of cause common most the become has rdiasis Gia- power. infectious their acquiring ment environ- the in development their complete ( form fully infective a in feces in excreted and produced pora sults obtained from obtained sults Cyclospora cayetanensis, emerging pathogen protists. pathogen emerging 1). ing 27,000 patients have been reported (Table From then until 1996, 122 outbreaks involv- A. ( stages immature like or Microsporidia), lamblia Giardia include disease waterborne with associated PROTOZOA PATHOGENIC VI. defined. better are pathogen this of occurrences environmental the while transmission, of epidemiology the for remains way long A pathogens. human H. pylori yt ( cysts ( cysts tract, intestinal the in ay irsoiin species Microsporidian many ylsoa Isospora Cyclospora, Giardia, Cryptosporidium Giardia, The Apicomplexan h ms peaet nei protozoa enteric prevalent most The oee, ay hrceitc make characteristics many However, As a result of proliferation and evolution ) or infective spore (Microsporidia) are (Microsporidia) spore infective or ) Cryptosporidium . 180 127,181,182,183,184,185 a special bacterium in the world of iri, Cryptosporidium Giardia, H. pylori H. and , hc wl shortly will which ), Cryptosporidium , h ls species, last The Cryptosporidium

Isospora belli, Cyclospora 186,187,188,189 infection in an in infection Giardia

per like appear , , oo- ), Isos- and has 383 2 , Downloaded By: [University of Florida] At: 16:15 31 December 2007 etgtos y Casemore, by vestigations ridium en eotd n h U.K. the in reported been ee met. were and whilecurrentmicrobiologicalstandards treatment, water of standards conventional with accordance in operated been had tems sys- processing when even water, potable cryptosporidiosis were found associated with and giardiasis of outbreaks many that was result striking A transmission. and etiology prompted investigations in depth about their severity of waterborne cryptosporidiosis have cases of illness. occurred in the U.S. that resulted in 419,914 tients. pa- immunocompromised among were recensed deaths 69 and hospitalized were corded re- over a span were of 2 months, diarrhea 4400 persons of cases 403,246 mated esti- An 1920. since U.S. the in ever cident in- waterborne documented largest the was the infection. the of source the as water ground contaminated 384 below. viewed re- briefly are These compliance. for toring be overcome in their management and moni- pat- terns forthesediseases,andtheproblemsto transmission the clarify to attempted et n Garcia, and rent 191,192 as a model protozoan pathogen, in- pathogen, protozoan model a as Enteric Protozoa and Waterborne-Disease Outbreaks Waterborne-Disease and Protozoa Enteric 1 TABLE 183,181,193 From 1985 to 1996, 10 outbreaks 190 184 The outbreak in Milwaukee in outbreak The 182 Many outbreaks have also eyn on Relying n Mihr e al. et Meinhart and 181 17 h sz and size The Rose, Cryptospo- 194 Cur- 183 2. .A ra vrey f nml reservoirs, animal of variety broad A 1. federal and state standards. According standards. state and federal met equipment processing where and filtered been had supplies water face sur- where communities hit 1993, however, and 1985 between U.S. the in occurred that cryptosporidiosis borne come the risk. the come over- theory, in should, filtration and coagulation by parasite the of moval water supplies. water drinking and plants treatment water of of water sources may lead to penetration chlorine dioxide. and ozone of exception the with tion, decontamina- water in used infectants stantially elevated resistance against dis- Cryptosporidium environment. the spread of for factor risk main the probably stitute numbers and in fully large infective form con- in animals and man by excreted transmission occurs frequently. Oocysts person-to-person and zoonotic dition, ad- In rainfall. abundant an by pounded com- effluents, human and cultural agri- through particularly environment, life spread oocysts to man and the water including farm livestock, pets, and wild- Cryptosporidium 183,194,195

17,183,196 All outbreaks of water- of outbreaks All 197,198 oocysts possess a sub- The contamination The physical re- in aquatic Downloaded By: [University of Florida] At: 16:15 31 December 2007 .The infective dose of 3. periments in human volunteers Ex- known. exactly not is humans in initiate an infection. may oocysts ten to one as few as that showed models animal using Studies jority of consumers are not. are consumers of jority ma- the whereas clusters, infectious to exposed be may persons some nisms, mecha- such By system. water the into biofilms, then be released by sloughing ridium ment developed by Perz by developed ment Nevertheless, themodelof riskassess- virulence. their on and stress, mental cysts that depends on incurred environ- oo- of viability the with strongly vary ter. wa- finished into oocysts of through filter backwash water can lead to break- recycling of practice the Also, tering. clus- pathogen affect coagulation) and which treatment process (e.g., filtration to degree the on information more for calls efficiencies of removal example, and performance criteria for treatments, for water, source from obtained ter wa- drinking in densities pathogen ing a median infective dose (ID dose infective median a indicating curves dose-response tained em o the of terms in oocysts 1000 and 10 between vary can volunteers immunocompetent for reported that the minimal infective dose Gale, to of less than 30. A more recent study recent more A 30. than less of dose infective minimum a and oocysts tracting infectious diseases. infectious tracting con- of risk the underestimate models current dispersed, randomly are gens others. By assuming that enteric patho- than doses higher much to consumers water drinking some exposing umes, to somedegree,evenwithinsmallvol- clustered are cryptosporidia, including that many pathogenic microorganisms, 201 ial, oyt of oocysts Finally, a atc t ad est in persit and to attach can 199 available evidence suggests evidence available Cryptosporidium 183,204 Cryptosporidium However, IDs et al. et Cryptospo- 200 50 202,203 ) of 132 of ) 185 Model- strain. tends ob- 4 .Recent molecular studies on 4. os not. does genotype human the while cattle, and mice readily infects genotype bovine the that shown have studies infection humans and livestock. Moreover, cross- infected both in found the was 2 genotype whereas humans, in only found the species in revealed were 2) and (1 genotypes isoenzymatic and molecular studies, two typical zoonosis. In fact, on a the basis of considered usually was sporidiosis crypto- human Consequently, humans. and animals both cryptosporidiosis for responsible like considered species the ridiosis. Untilrecently, cryptospo- of pattern demiological basically the usual views about the epi- ridium ahgn n rnig water. drinking in the pathogen of levels low at occur may cysts to demonstrate that transmission of oo- marsupial, and monkey). Furthermore, monkey). and marsupial, wild mammals (dog, mouse, pig, ferret, parvum C. in identified were genotypes other six genotypes, human and bovine major two the to addition in Thus, complex. are revealing a situation that is still more studies subsequent However, humans. through passes exclusively that other and animals, or humans in occur may that one cycles: transmission separate suggest the existence of two break. out- Vegas Las the in as levels oocyst detectable of absence the in however, related, been have cases Waterborne e epsto t ol oe oocyst. one only to exposition ter af- infected become indeed might sons per- that suggest data epidemiological mathematical modeling combined with epidemic, Milwaukee the to respect genetically isolated. are genotypes two the that indicated 206 eei dvriy r changing are diversity genetic 207,208,209 slts rm oetc or domestic from isolates C. parvum utlcs analysis Multilocus 210,211 . Genotype 1 was C. parvum Theseresults Cryptospo- C. parvum 205 With was 385 192 Downloaded By: [University of Florida] At: 16:15 31 December 2007 pora, like protozoa Apicomplexa tients. pa- AIDS in rates infection high their of cause be- attention received have species recently all, Over- transmission. of routes waterborne have may and pathogens opportunistic as emerging ikd o aebre transmission waterborne to linked Cyclospora of outbreaks Several countries. veloping de- visited had who travelers in and ditions con- sanitary poor in living children among gastroenteritis in described primarily was 5. In immunocompromised persons, par- persons, immunocompromised In 5. B. 386 case one only in but ylsoiss afcig oe hn 1400 than more affecting cyclosporiasis, of outbreak reported ever largest the 1996, In water. drinking in demonstrated oocysts Microsporidia Cyclospora, Isospora Cyclospora, In addition to Before 1995, the parasite n mn Mcoprda species Microsporidian many and lates, or environmental animal, human, of identification type lecular methods allow species or geno- tients. pa- AIDS were victims of majority the outbreak Milwaukee the in deaths 69 the Among patients. AIDS in reaction fulminant more the substantiated have waterborne cryptosporidiosis outbreaks result in death of the former. may which people, immunocompetent in than severity greater a of are illness of symptoms patients, AIDS ticularly on bases. molecular defined being are patterns sion onomy and cryptosporidiosis transmis- the species the Old World. Old the fied in human patients from the New or C. felis, 186,188,214,215 213 191 infection (or isolated cases) have and new Giardia C. meleagridis C. muris Cryptosporidium 212 Cryptosporidium 216 Indeed, as only mo- only as Indeed, and were have been identi- Cyclospora Cryptosporidium C. cayetanensis , (from birds), Cyclospora 185,183 216,217,218 , Most Isos- iso-

tax- are , this route. this sible and some epidemiological data pos- suggest is parasite this of transmission borne AIDS. with patients as such causes gastroenteritis in immunocompromised commonly hosts, most that protozoa the Apicomplexa The haps having been passed through these hosts. et al. et transmission, pathogens of that have potential group for waterborne a as recognized been have They cornea, conjonctiva, liver, and affecting biliary tract infection. infection ocular as well as infection systemic cause to disseminate in water. in the detection of human for pathogenic Microsporidia developed was methodologies of ducks, chickens, dogs, and primates, and dogs, chickens, ducks, from recovered been have organisms like of traveler’s diarrhea. traveler’s of Microsporidia could also be a possible cause vegetables. and sources water from numbers limited in limitations, technologic Notwithstanding source. rect indi- the was fruit, on biocides spraying for mala. Most Guate- likely, fecal-polluted water, used from raspberries fresh eating with ay nw aia hosts, animal known many are the following They persons. immunocompromised in rily prima- disease human with associated been vertebrates. Five microsporidian genera have of classes all and invertebrates most cludes in- and extensive is range host Their sites. para- protozoan spore-forming tracellular, persons in North America North in persons ain by nation trointestinal infection in gas- AIDS patients; cause that parasite Microsporidian intestinalis E. and litozoon Unlike irsoii poit ae biae in- obligate, are protists Microsporidia Nosema 227 shows a low rate of water contami- water of rate low a shows , 226 Trachipleistophora 6 . bienensi E. However, the study by Fournier by study the However, 188,191 Cyclospora Cryptosporidium, . 14,225 Enterocytozoon bienensi, Enterocytozoon r te ot prevalent most the are and recently an evaluation Enterocytozoon ssoa belli Isospora 224 sgetn ta the that suggesting , have been recovered Microsporidia may Microsporidia 219 220 was associated was 221 ,

hc has which Vittaformae, Cyclospora h water- The , s among is Encepha- 187 222,223 per- and - Downloaded By: [University of Florida] At: 16:15 31 December 2007 logical significance (Table 2). (Table significance logical epidemio- their to respect with categories sewage. into way their find and the humangut.Theyareexcretedbypatients more than140distincttypes,canbefoundin 15 differentgroupsofviruses,encompassing waterborne outbreaks. producing of capable virus enteric identified of hepatitis recognition E virus (HEV) and the the more recently by characterized is ogy PATHOGENS VIRAL VIII. limited. risk of waterborne transmission to humans is These viruses can be divided into three into divided be can viruses These The modern era in environmental virol- environmental in era modern The Transmitted by Fecally Polluted Water Polluted Fecally by Transmitted Be Can That Pathogens Putative or Pathogens Viral Human 2 TABLE 228,229,230,231,232 More than 3. A third category encompasses putative encompasses category third A 3. Arelativelysmallgroupofviruseshas 2. nonenteropathogenic, either are Some 1. is still unproven. still is reovirus, for which a causal relationship and parvovirus, torovirus, enterovirus, coronavirus, as such enteropathogens, astroviruses, and some enteric adenoviruses. rus and other caliciviruses, rotaviruses, vi- Norwalk include they agents; logic etio- true be to proven been have still fewer and humans, in gastroenteritis been incriminated as the causes of acute enteroviruses. human some other and viruses, E and A hepatitis echovirus, B, and A coxsackieviruses poliovirus, include these epithelium; gut the with unrelated illness cause or 228 387 Downloaded By: [University of Florida] At: 16:15 31 December 2007 n 91 o 1990. to 1981 in outbreaks 11 and 1980 to 1971 in outbreaks 16 with 1971 since declined has It illness). of cases (896 outbreaks 29 and illness) of cases (757 outbreaks 18 respectively, with, has been in 1950 to 1960s and 1961 to 1970s U.S. the in of hepatitis infectious incidence waterborne highest The water. by sion transmis- supporting features show them of Twenty-nine 1964. to 1895 from outbreaks eae oltd ae my osiue a source. constitute may water polluted sewage therefore and route, fecal-oral the by mitted and sporadic cases of hepatitis; they are trans- epidemics with associated are (HEV) virus Hepatitis A. 388 reported. were A virus hepatitis by caused outbreaks Mosley children. young in infections as- ymptomatic of cause important an constitutes and epidemics widespread in results It virus. A hepatitis is outbreaks waterborne with ated epidemiological knowledge over the years. is based largely on guidelines developed from causality demonstrating in step second The culture. in grown has it after or sessment, as- immunological (PCR), biology lecular mo- by virus the of identity the establishing on relies procedure confirmation attempted an in step first The diarrhea. of agent ative caus- the indeed is virus the that prove not men fromapatientwithgastroenteritisdoes at oe (0) I 19, h largest yet E hepatitis viral the of outbreak waterborne 1991, In (20%). women nant of preg- in mortality increased incidence and cholestasis high a with than A, severe hepatitis more be can Infection areas. subtropical and tropical to confined mostly Hepatitis A virus (HAV) and Hepatitis E The most established virus group associ- The occurrence of a virus in a fecal speci- Hepatitis E is much less widespread and 17 234 235,236 a smaie rprs f 50 of reports summarized has 2,8 ic 19, ny two only 1991, Since 233 (SLV). viruses Sapporo-like and (NLV), ruses vi- Norwalk-like lagovirus, vesivirus, genera: The SRSVs. family other 50 over like calicivirus, as identified been have these of Most Osaka agents. the and Sapporo, Otofuke, Taunton, Country, Montgomery Mountain, Snow waii, Ha- the induded These (SRSV). viruses tured struc- round small as IEM by classified later Ohio, in 1968. Many other related viruses were troenteritis in an elementary school in Norwalk, gas- epidemic of outbreak an from originated This virus. Norwalk termed agent the was tis have been identified as a cause of gastroenteri- ADVR. or rotavirus diarrhea adult as designated therefore ease, dis- diarrheal adult for predominantly sible human respon- are other rotaviruses B group to rotaviruses, contrast In years. 4 to cause diarrhea in young children, age 4 months principally strains, A group like rotaviruses, C Group children. young and infants in ease dis- diarrhea of cause common most the are rotaviruses A Group serotype. and subgroup, C, and B, A, groups antigenic by classified and some enteric adenovirus. Rotaviruses are teritis include rotavirus, calicivirus, astrovirus, Gastroenteritis Viral B. voir hostsofNLVs. data suggest that calves and pigs may be reser- recent but humans, in only found been have aebre n cue b HEV. by caused and waterborne invariably are epidemics hepatitis scale urd n eh i 15 t 15 affected 1956 approximately 29,300 to persons. 1955 in Delhi in curred be prevalent at a low level in Europe. in level low a at prevalent be cent evidence indicates that HEV might also ease. dis- of cases 79,000 over of total estimated reported occurred in Kasspur, India, with an h ms ntros f aiiiue that caliciviruses of notorious most The gastroen- of agents viral recognized The 237 Caliciviridae 242 nte wtron otra oc- outbreak waterborne Another Viruses in the NLV and SLV genera includes the following four 232 Genetically,thehuman 238 Such large- 239,240 241 Re- Downloaded By: [University of Florida] At: 16:15 31 December 2007 G, GI L, n GII SLV. GGIII and NLV, GGII GGI, is, that (GC), genogroups or clusters genetic three least at contains CVs) (Hu caliciviruses correlated with serotypes. with correlated B and A genogroups two identified analysis of unidentified origin (AGI) is indeed associ- likely that a marked fraction of gastroenteritis than more is it However, 2. Figure in- in cluded been not have they incidence low their of Because 1996. to 1991 from 1 1990, and 10 between 1971 and 1980, 15 between 1981 infrequently: occur water drinking of breaks days. 10 to 8 lasts period incubation the but rotavirosis, of that to lar picture of adenovirus gastroenteritis is simi- mean incubation time of 2 days. a The clinical after days 4 to 1 from lasting symptoms with self-limited, but explosive typically astrovirus gastroenteritis are generally mild, and Calicivirus countries. developing in especially death, and dehydration severe in result can rotavirosis untreated, If world. the in gastroenteritis infantile of causes tant (EAd). adenoviruses enteric to referred loquially col- are subgroup F the from serotypes two ther divided. ther fur- be can genogroups these indicate strains ever, recently accumulated sequences of HuCV tently associated with gastroenteritis. with associated tently consis- been have 41 and 40 types only but of types adenoviruses have been isolated Many from stools, F. through A groups sub- six into subdivided adenoviruses, man (RT-PCR). reaction chain croscopy or reverse transcriptase-polymerase enzyme immuno-assays immunoelectron mi- astroviruses (HAstV) have been identified by human of serotypes seven date, To particles. viral the of surface the on evident was that configuration star six-pointed or five- teristic charac- the for astrovirus named were arrhea In American statistics viral enteritis out- enteritis viral statistics American In impor- most the of one are Rotaviruses There are currently 47 serotypes of hu- of serotypes 47 currently are There di- with stools infant from SRSVs Some 244,245,246,247,248 251 249,250 Phylogenetic 243 252 How- The ih obceil gastroenteritis. nonbacterial with patients of feces the in regularly found ated to humans gastroenteritis humans to ated associ- been have Coronaviruses etiologic agent. the necessarily were all not diarrhea, with patients from specimens fecal in identified be could them of most of acute gastroenteritis in causes humans, but while the as incriminated been has Viruses Candidate Other C. supplies. water drinking by viruses of transmission low-level suggests that data cently, immune response has been intro- been has response immune cently, re- More controls. healthy in found also mains to be determined because many are re- population human the in diarrhea of agent etiologic an as role their However, ait o etrc iue. h rsls ob- results tained The wide viruses. a enteric of of levels variety low detect to possible it reaction (RT-PCR) available now have made on the reverse transcriptase-polymerase chain The sensitive new molecular techniques based tance asacauseofillnessintheNetherlands. impor- in rotaviruses exceed may NLVs that o owl vrss cu truhu the year. throughout occur viruses Norwalk to owing infections of number large a that firm con- seroprevalence of studies demiological n HVifce patients. HIV-infected and gastroenteritis, with adults and children from specimens fecal in identified also were parvoviruses and reoviruses, ruses, enterovi- toroviruses, picobirnaviruses, as such viruses been Other have inconclusive. far so results the causality, spite 2 decades of research to assess their natal necrotising entero-colitis waterborne outbreak reports. outbreak several waterborne in revealed was NLVs, especially In II). recent years, the predominant part of SRSVs, (Section aetiology viral a with ated rltvl sal ru o viruses of group small relatively A 257 154,231,258 Data

lo upr epidemiological support also rm Lodder from

t al. et 253,254,255,256 260 233,249,261,262 259 229 and were to neo- to suggest 261 De- Epi- 389 Downloaded By: [University of Florida] At: 16:15 31 December 2007 .Vrss fud n h fcs f symp- of feces the in found Viruses, 2. .The wide distribution of enteric viruses 3. 1. More than 140 types of human or ani- or human of types 140 than More 1. outbreaks. waterborne in role important potentially their to point Infections Viral Affecting Factors D. tions. investiga- such in parameter a as duced 390 for applied been have methods Many 4. Certain characteristicsofentericviruses numbers up to 10 attain hosts asymptomatic or tomatic species. mal to cause gastroenteritis in different ani- known are specimens diarrhea human in found astroviruses) (caliciviruses, n a swg cn ec 10 reach can sewage raw in detectable currently viruses of number The weeks. 4 to 1 for excreted gram, that they may promote further cluster- further promote may they that is treatments water of limitation main tive. posi- testing adults the of most tions: cal surveys of North American popula- sero-epidemiologi- by demonstrated is liter. per units infectious mans. hu- in enteropathogens putative being have just other enteropathogenicity, them proven of Some 2). (Table age mal enteric viruses can be found in sew- tl ocsoal detectable. occasionally still are viruses treatments, water drinking After volumes. of large within pathogens dispersion random no and fects, ef- seasonal water, raw of load crobial mi- in variation the as such comings, of bacteria, and various analytical short- that than higher much being resistance their virions, the of 100 multiplicity to nm), (20 size small the by marred all water; from viruses eliminating 233 257 233 Mostofthenovelviralagents 10 infectious doses per 2 263 o 10 to The 3 outbreak reporting system is voluntary, the voluntary, is system reporting outbreak waterborne Because 1980. to 1970 in 177 and recorded were outbreaks 213 1950, to ogy could not be determined. Between 1940 etiol- the U.S., the in related gastroenteritis ETIOLOGY UNDETERMINED OF GASTROENTERITIS IX. 6. In some waterborne outbreaks of gas- of outbreaks waterborne some In 6. 5. The number of viruses required to ini- to required viruses of number The 5. n h mjrt o otras f acute of outbreaks of majority the In viruses in water. of in viruses occurrence the monitor to equate that bacteriological indicators are inad- indicates water potable safe” logically can be as high as 1:1000 or more. or 1:1000 as high as be can tron microscopically detectable viruses elec- among culturable of proportion infectious viruses”. For rotaviruses, the of number real the of fraction a only is stated, “The cell culture infectious unit with Norwalk and related viruses, of infectious units: Payment units: infectious of to infect man or animals is low in terms pears that the number of virions needed 10 ID50 are generally high, on the order of the bacteria enteropathogenic most the astroviruses, of viruses from samples of “bacterio- of samples from viruses of chlorine level. adequate an contained and standards bacteriological current met that water from isolated were viruses troenteritis, II). tion models. rge dsae n animal in disease trigger can rotavirus of particle infectious one as little as conditions, appropriate der Un- volunteers. human or models mal ani- in estimated be can infection tiate others. than doses ter-drinking consumers to much higher wa- some exposing pathogens, of ing 6 to 10 265 8 except some species (cf. Sec- rm tde i volunteers in studies From 268 2,269,271,272,273 enteroviruses, The isolation 264 r human or 269 265 rightly t ap- it 270 266,267 In Downloaded By: [University of Florida] At: 16:15 31 December 2007 example, erotrophic, potentially pathogenic agents, for that time. Even in at 1970 to 1980 impossible was pathogens viral enteric Payment et al. et Payment standards. bacteriological with complying water drinking with endemic associated at infections point to seem France in later GASTROENTERITIS ENDEMIC X. agents. etiologic as Cryptosporidium ments. recording by State and Local Health Depart- occurrence might be largely attributed to poor differences observed in the frequency of their ad. amn e al. et Payment dards. stan- quality water physicochemical and cal microbiologi- American North the meeting procedures disinfecting dioxide chlorine or chlorine final and ozonation, filtration, sand flocculation, predisinfecting, included system water community the in used ment treat- the that despite filter, water domestic a with provided those than (35%) illnesses gastrointestinal acute of rate higher cantly signifi- a had drinkers water tap that municipal showed study This completed. been has water surface contaminated logically bacterio- of treatment well-conducted dard, the health hazard, which remains after a stan- quantify to order in design trial randomized like virus infection. epidemiologically consistentwithNorwalk- and clinically were outbreaks some Also, procedures effectively eliminate disinfecting these agents. and filtration while identify, origin. viral of be could outbreaks these of many etiology, protozoan or bacterial a have could dents been confirmed, however, while this dispro- for these incidents. This assumption has never A fewstudiescarriedoutinCanadaand bceil as i rltvl es to easy relatively is cause bacterial A 2 lhuh i picpe mn inci- many principle, in Although, Bacillus 274,275 were only rarely recognized spp., could be responsible 9 in Montreal, followed a followed Montreal, in Finally, the detection of 276 ugs ta het- that suggest Giardia and persons that drank nonfiltered city water. city nonfiltered in drank that persons highest were infection of rates cases; indeed, related non-outbreak of cause tant impor- an be to suggested was transmission waterborne states, other than higher rates most common disease with annual incidence continuous. is tion contamina- microbiological that suggesting water, on relying in greater still is events tis the routine occurrence of acute gastroenteri- eis wr ecue fo te analysis, the from excluded were demics’ ‘epi- with days when Even infection. tinal an endemicoccurrenceofacutegastrointes- with along outbreaks, sporadic small prises com- study this in observed morbidity The controls. among than water treated drinking was 1.4 times more frequent among children ens t al. et Dennis demic en- for route exposure important an resent low-level transmission via tap water can rep- that showed analysis the for cryptosporidiosis, data surveillance with output model Cryptosporidium with infections endemic in water tap of role potential the examine to model assessment cluding filtration. Perz et al. et Perz filtration. cluding in- technology, purification water to tance occurrence in surface water and higher resis- rdia enhanced endemic risks compared with giardiasis. endemic with ated ational water exposure were strongly associ- recre- and water surface untreated drinking Fraser and Cook and Fraser These observationshavebeenconfirmedby et al. cal study was conducted in France by Zmirou cessed from ground water, an epidemiologi- pro- water piped of disinfecting mere after by other authors. other by the studied water supplies has not been found of percentage high portionately n emn, hr gadai ws the was giardiasis where Vermont, In Cryptosporidium In order to assess the residual health risk 278 p. bcue f hi mr frequent more their of because spp., Cryptosporidium Thecrudeincidencerateofdiarrhea 281 n e Hmsie where Hampshire, New in 280 277 p. n oprn the comparing In spp. in New Zealand and by and Zealand New in spp. probably present probably spp. infection. 185 used a risk a used Bacillus Gia- 391 in 279 Downloaded By: [University of Florida] At: 16:15 31 December 2007 curred in 1994 in Clark County (Nevada), County Clark in 1994 in curred oc- that outbreak the In patients. compromised immuno- amongst recorded were fatalities 69 392 threatening. life and severe more is illness while persons, crypto- acquire sporidiosis morelikelythanimmunocompetent can patients, AIDS as such borne outbreaks immunocompromised persons, water- during that indicate data current died. Thus, 32 whom among adults, HIV-infected 63 of the 78 laboratory confirmed cases were in outcome. In the Milwaukee epidemic, lethal potential a for and illness, severe oping devel- for persons immunocompetent than risk greater at are patients, AIDS as such persons, it has been observed that immunocompromised SUBJECTS IMMUNOCOMPROMISED OF EXPOSURE ACCOUNT INTO TAKING XI. supply. water drinking safe ditionally uncon- an at aiming treatments purification water applied customarily in im- provements for call well may investigations of such outcome The subjects. control cluding in- pathogens, of levels different to posed ex- been have that populations on studies prospective by provided be to has mation infor- Such data. analytical and miological epide- supplemental many for call fections in- waterborne of transmission endemic of lower. treatments rification pu- water to resistance their and higher ally usu- is dose infectious their because likely role for bacterial enteropathogens seems less similar a hand, other the On gastroenteritis. involved in outbreaks of endemic waterborne be might viruses enteric Similarly, waters. treated in clusters in distribution geneous of these organisms for man, and their hetero- fections results from the low infectious dose In all waterborne cryptosporidiosis outbreaks These data demonstrate that management in- protozoan of transmission Endemic 192 at least 193,282 1900s. Therefore, some early bacterial agents ing countries have declined dramatically from develop- the in fever) typhoid (particularly oocysts. or units bacteria, in the range of one to ten infectious than lower is agents protozoan and viral of and to most disinfectants. The infection dose environment water the in resistant are strongly which protozoa, enteric and ruses, vi- enteric bacteria, aquatic and enteric ing tions. Therearebacterialpathogens,includ- infec- waterborne initiate to able are feces SUMMARY oocysts. of levels low of significance studies designed for assessing the public health epidemiologic by and systems surveillance by guided be should efforts Such water. drinking low-level oocyst contamination of fully treated ligation to manage health risks associated with ob- the from however, authorities, these empt ex- not does This pools. swimming public or water andavoidingswimminginlakes,rivers, bottled or filters, water using use, before ter water- borne cryptosporidiosis, including boiling wa- for risk the reducing at aiming sures mea- specific take to recommending YOPIs to launchaninformationcampaigntargetedat gens. This prompted Public Health Authorities Cryptosporidium specifically more protozoa, to from exposure particularly risks, more incur to seem (YOPI) category. (YOPI) immunocompromised and pregnant, old, young, very the subjects: debilitated of group classic the for risks enhanced substantially of patients with AIDS. immunocompromised of overrepresentation pora cases of cyclosporiasis, and diarrhea with Waterborne outbreaks of bacterial origin in excreted pathogens of classes Many o srrsnl, oe eety reported recently more surprisingly, Not r irsoii i sol include stools in Microsporidia or spp. than from other patho- other from than spp. 200 184 It is striking that YOPIs that striking is It This follows the pattern Cryptosporidium Isos- Downloaded By: [University of Florida] At: 16:15 31 December 2007 borne cryptosporidiosis in Milwaukee, Wis- water- of outbreak massive the of result a as However, years. 30 last the over U.S. the in disease waterborne human of cause mon substantiated. be to need sumptions lori mission. Therefore,itispossiblethat trans- fecal-to-oral suggests strongly which fied from feces samples of infected patients, that been has proven. relationship the cases some in infection; of source a as suggested been has fections in AIDS patients and drinking water in- disseminated causes frequently complex dential and hospital water supplies. caused by disease Legionnaires’ reported have ies stud- Numerous supplies. water hot and ing drink- in niche ecologic an found have that pathogens environmental are (MAC) plex Legionella studies. epidemiological further in ated gastroenteritis remains a debatable acute point and has to of be evalu- occurrence the to cance of cance ingested with infection to refractory is population general the risk, at hosts specific than Other tems. sys- distribution water in proliferating and mental bacteria that are capable of surviving epidemic. on serotype O139 of of 1992 early in emergence The disease. trigger may that cells) hundred few ture ofthesebacteriaisthelowinoculum(a or domesticanimalfeces.Thecommonfea- contaminate pristine waters through wildlife zoonotic as such origin fecal of pathogens new and types than sero- other that suggests Asia Southeast in uh as such neto i wtron, u tee as- these but waterborne, is infection iriss a bcm te ot com- most the become has Giardiasis show reports numerous more and More oe e ptoes nld environ- include pathogens new Some Helicobacter pylori V. cholerae hgla sonnei Shigella C. jejuni Aeromonas L. pneumophila and V. cholerae . aeruginosa P. Mycobacterium avium Mycobacterium and with epidemic potential spp. in drinking water drinking in spp. O1 could also getting E. coli DNA can be ampli- ean prevalent remains occurring in resi- O157:H7 may Te signifi- The . M. avium H. py- com- waterborne illnesses world-wide. illnesses waterborne viruses arerecognizedas the majorcausesof Norwalk-like and virus Norwalk Actually, etiology currently reported are unknown likely due to viral of agents. outbreaks many but technology, diagnostic inadequate of cause be- outbreaks, disease waterborne of agents etiologic the as identified been infrequently enteric adenovirus. These some enteric viruses have and astrovirus, calicivirus, rotavirus, including agents, etiologic true be have to proven fewer and humans in acute gastroenteritis of causes as incriminated been have viruses of group in small relatively level A low Europe. a at occur can it that indicate reports recent but areas, subtropical and cal the 1970s. Hepatitis E is since mostly confined to tropi- countries developing in declined and 1970,theincidenceratehasstrongly 1950 between U.S. the in documented been virus (HEV). Numerous large outbreaks have E Hepatitis and (HAV) virus A Hepatitis as illness unrelated with the gut epithelium, such cause Some gut. human the in found be can types distinct 140 than more encompassing transmission. of routes waterborne ing as opportunistic pathogens and may have pora, In addition to the endemictransmissionofentericdisease. pathogen occurrence may be responsible for of levels low that persists concern stantial gens, especially from protozoan agents. Sub- patho- all from free is water that guarantees equate, and that a negative coliform no longer inad- become have technologies treatment water that demonstrates standards quality through treated water supplies that meet water of mission well asmonitoringwaterquality.Thetrans- by caused infection disease new of prevention and miology sons, there is increasing interest in the epide- per- 403,000 estimated an affecting consin, oe pce o genera of species some More than 15 different groups of viruses, and of family Microsporidia are emerg- Cryptosporidium Giardia Cryptosporidium and Cyclospora Cryptosporidium and Giardia spp. as spp. , Isos- 393 , Downloaded By: [University of Florida] At: 16:15 31 December 2007 394 REFERENCES growing, population. weaker this in diseases infection borne water- of risk the reducing at aimed sures mea- specific take to of requirement basic the and individuals) and immunocompromised pregnant, old, young, (very jects risks for the classic group of debilitated sub- Other concluding concerns are the enhanced procedures. disinfecting chemical including factors, environmental relevant to resistant highly being drinking, for intended water endemic of transmission, because they are ubiquitous in levels highest the reach to as as such caliciviruses and some viruses protozoan agents, such enteric that is concern striking most The diseases. waterborne of bers highly underestimate the real incidence borne disease is considerable. 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