ENVIRONMENTAL HEALTH MODULE: FOOD- & WATER-BORNE DISEASES

PRESENTED BY.
Food- and Water-Borne Disease
Section A

Food-Borne Diseases
 Food-Borne Diseases: Definitions
„ Food-borne diseases
− Those resulting from consumption of any solid food or
milk, water, or other beverage
„ Outbreak (CDC)
− Two or more persons experiencing a similar illness after
ingestion of a common food or beverage
− Epidemiologic analysis implicates the food/beverage as
the source of illness

Source: MMWR.
4
 Food-Borne Outbreaks: 1988–1997

700 25000
600
20000
500
Outbreaks

400 15000

Cases
Cases
300 10000
200
5000
100
0 0
89

90

93

94

96

97
88

91

92

95
19

19

19

19
19

19

19

19

19

19
Outbreaks Cases

Source: MMWR.
5
 Total Burden of Food-Borne Illness

Illnesses 76,000,000

Hospitalizations 323,000

Deaths 5,200

Source: Mead, P. S. et al. (1999). Food-related illness and death in the United States. EID, 5, 607–625.
6
 Causes of Food-Borne Outbreaks, 1988–1997

60

50

40
Percent

30

20

10

0
Unknown Bact. Chem. Viral Parasitic

Source: MMWR.
7
 Number of Causative Organisms
„ Number of causative organisms involved in confirmed food-
borne illnesses
40
Number of Causative Agents

30

20

10

0
1950 1960 1970 1980 1990 2000

Source: MMWR.
8
Extent of the Problem

OCCUR?

REPORTED

Food known, agent known, causes known 9

Food Safety Issues

Microbial
Contamination

Food Natural
Food
Additives Toxins

Environmental
Pesticide
Contaminants
Residues
10
Selected Infectious Agents and Their Main Habitats

Microorganism Main habitat

Bacillus cereus,
Ubiquitous in soil and on vegetables
Clostridium botulinum

Campylobacter Intestine of animals, fowl, and humans

Lower intestine of humans, warm-

E. coli, Salmonella
blooded animals, birds

Shigella Intestine of humans and primates

Staphylococcus aureus Common on human skin and oropharynx

Vibrio cholerae Intestine of humans

11
Selected Infectious Agents and Their Main Habitats

Microorganism Main habitat

Intestine of humans, beavers, and
Giardia lamblia
muskrats

Intestine of humans and warm-blooded

Cryptosporidium
animals

Striated muscle of carnivorous and

Trichinella spiralis
omnivorous animals

Hepatitis A virus Intestine of humans

Norwalk virus Intestine of humans

12
 The Bacterial Growth Curve
9

8
c

7 a: Lag d
b: Exponential (logarithmic)
Log10/ml

6 c: Stationary
d: Decline
5
b
4

3
a
2
0 4 8 12 16 20 24 28 32
Hours at 37oC
13
Minimal Infective Doses
„ Minimal infective doses for some pathogens and parasites

Organism Minimal dose

Salmonella spp. 104–107

Shigella spp. 101–102

Escherichia coli 106–108

Escherichia coli O157:H7 ~10

Vibrio cholerae 103

Giardia lamblia 101–102 cysts

Cryptosporidium 101 cysts

Hepatitis A virus 1–10 PFU

14
Multiplication of L. monocytogenes in Broth
„ Multiplication of L. monocytogenes in broth at low
temperature
8

7 4o C

6
Bacteria per ml

3
-20oC
2

0
0 1 3 6 12
Weeks of storage
15
 Preferred Temperature Ranges for 4 Types of Bacteria
„ Relative growth rate of bacteria at different temperatures

Source: Doyle, M. P.
16
Extension of Shelf Life of Raw Foods by Cool Storage

Average useful storage life (days)

Food 0oC (32oF) 22oC (72oF)

Meat 6–10 1

Fish 2–7 1

Poultry 5–18 1

Fruits 2–180 1–29

Leafy vegetables 3–20 1–7

Root crops 90–300 7–50

17
Moisture Requirement
„ Water activity; aw

Water vapor pressure of food

Aw=
Water vapor pressure of pure water

„ Free water in food is necessary for microbial growth

„ Each microbial species has an optimum, maximum, and
minimum aw for growth
„ In general, a higher aw facilitates microbial growth

18
Water Activity of Various Foods

Food aw
Fresh fruit, vegetables, meat, fish >0.98
Cooked meat, bread 0.95–0.98
Cured meats, cheeses 0.91–0.95
Sausages, syrups 0.87–0.91
Rice, beans, peas 0.80–0.87
Jams, marmalades 0.75–0.80
Candies 0.65–0.75
Dried fruits 0.60–0.65
Dehydrated milk, spices 0.20–0.50

19
Lowest aw Values Permitting Growth of Microorganisms

Group of microorganisms Minimal aw value

Many bacteria 0.91

Many yeasts 0.88

Many molds 0.80

Halophilic bacteria 0.75

Osmotic yeasts 0.60

20
Oxygen-Reduction (O-R) Potential
„ O2 tension or partial pressure of O2 about a food and the O-R
potential (the oxidizing and reducing power of the food)
influence the types of organisms that will grow in the food
„ Aerobes—Require free oxygen
− Most microorganisms
„ Anaerobes—Grow best in the absence of free oxygen
− Clostridium spp.
„ Facultative—Grow well either aerobically or anaerobically
− Enterobacteriaceae family

21
pH

22
Foods Associated with Foodborne Illness

Food vehicle Microorganism

Salmonella, S. aureus, E. coli, B. cereus, T. spiralis, L.

Beef and pork
monocytogenes

Salmonella, Campylobacter, S. aureus, L.

Poultry
monocytogenes

Salmonella, Campylobacter, E. coli, L. monocytogenes,

Dairy products
Brucella

Eggs Salmonella, S. aureus

Dried cereal B. cereus and other Bacillus spp.

23
 Foods Associated with Foodborne Illness

Food vehicle Microorganism

C. botulinum, C. perfringence, Salmonella, Shigella, B.

Vegetables
cereus, Norwalk virus

C. botulinum, C. perfringence, ciguatera and scombroid

Fish
toxins
V. parahaemolyticus, V. cholerae, Hepatitis A, Norwalk
Shellfish
virus, neurotoxic and paralytic shellfish poisoning
Chinese food B. cereus (in fried rice)

24
Some New Food Vehicles for Transmission
„ Internal content of eggs
− Salmonella enteritidis
„ Apple cider (low pH)
− E. coli O157:H7
„ Imported raspberries
− Cylospora
„ Oysters
− Norwalk-like virus

25
Changes in Host Susceptibility
„ Increase in diseases that cause immunosuppression
− AIDS 1988–1996: 22,000 to 223,000 cases
„ Increase in use of immunosuppressive agents
− Number of organ transplants
1988–1996: 12,000 to 22,000
„ Aging of the population
− Percentage of U.S. population >65 years old: 1950–1990:
8% to 15%

26
Host Factors and Susceptibility/Resistance to Infection
„ Personal hygiene
− Sanitary conditions; number of organisms ingested
„ Gastric acidity (pH ~ 3.4; acid barrier)
− 99.9% of ingested coliforms killed within 30 minutes
− Majority of pathogens never reach intestine
− Antacids increase susceptibility and severity of
gastrointestinal infections
„ Intestinal motility
− Fluid absorption processes
− Maintaining appropriate distribution of indigenous
enteric microflora
− Ridding host of pathogenic microorganisms
„ Specific immunity

27
Section B

Water-Borne Diseases
 Global Total Water and Freshwater Reserves

Total water resources Freshwater resources

Rivers, lakes,
Permafrost swamps
Other 0.97% 0.34%
0.97%

Groundwater
Oceans Freshwater 29.9%
96.5% reserves 2.53%
Glaciers and permanent
snow cover
68.7%

Source: Pickering, K. T.
29
 The Hydrologic Cycle

Source: Adapted by CTLT from Nadakavukaren, A.

30
Sources of Freshwater
„ Groundwater
− Available at point of need at little cost
− Until recently was not polluted
„ Surface water
− Usually requires extensive purification
„ Protected runoff
„ Ocean and brackish waters
− Costly to desalinate

31
Water System Facts

32
Freshwater Facts
„ Body composition
− Body, 65% water; blood, 83%; bones, 25%
− Water loss: 1% thirst; 5% hallucinations; 15% death
„ Basic requirements for safe water
− Drinking: 2–3 liters/day
− Minimum acceptable standard for living (WHO)
X 20–50 liters/capita/day for cooking and basic hygiene

33
 U.S. Water Consumption and Population Growth Rates

Daily withdrawal (billion gallons)

Total population (millions)

600 600

500 500

400 400

300 300

200 200

100 100
1950 1960 1970 1980 1990

Water consumption Population

Source: Gabler, R. 34
 Distribution of U.S. Domestic Household Water Use

Use Gallons/capita/day Percent of total

Toilet flushing 23 40

Body washing 20 37

Drinking 3 5

Laundry 4 7

Dishwashing 4 7

Garden watering 3 5

Car washing 1 2

Total 58 100

All other* 1359

*Irrigation, livestock, commercial, industry, mining, etc.

Source: Tchobanoglous, G. 35
Current Water Issues
„ Vulnerability of surface water to:
− Drought (not replenished); i.e., lakes, reservoirs
− Diversion of rivers for agricultural and urban use
„ Declining groundwater levels
− Failure to replenish
− Compaction of aquifers
− Saltwater intrusion
„ Surface water pollution from nonpoint sources
„ Groundwater pollution
„ Increasing competition for water supplies
− World’s available freshwater is not distributed evenly

36
 Sources of Groundwater Contamination

Source: Adapted by CTLT from Nadakavukaren, A. 37

 Surface Water Contamination
„ Point and nonpoint sources of surface water contamination

Source: Adapted by CTLT from Bucholz, R. A. 38

 Classes of Water Pollutants

Oxygen-demanding wastes Plant and animal material

Infectious agents Bacteria, viruses, protozoans
Plant nutrients Fertilizers: nitrates, phosphates
Organic chemicals Pesticides, detergents

Acids from coal mine drainage, inorganic

Inorganic chemicals
chemicals from steel plants

Sediment from land erosion Clay silt on stream beds

Waste products from mining and
Radioactive substances
processing
Cooling water used in steam generation of
Heat from industry
electricity

Source: McKinney, M. L. 39
 Major Causes of Stream and River Pollution

17% Municipal sources

Nonpoint
sources 9% Industrial sources
65%

6% Dredge and landfill

3% Unknown

Source: Wagner, T. 40
 Water Purification
„ Goals
− Provides safe source of water that meets quality
objectives
− Reasonable cost
„ Sources
− Surface water
X Serves 52% of the U.S. population
− Groundwater
X Serves 48% of the U.S. population

Source: Patrick, R.
41
 Typical Contaminants Found in Raw Water
„ Typical contaminants found in raw water that need to be
removed to meet specific water quality criteria

Class Groundwater Surface water

Branches, leaves, algal mats,

Bulky materials None
soil particles

Microorganisms, trace Clay, silt, organic materials,

Colloidal materials organic and inorganic pathogenic organisms, algae,
material other microorganisms

Source: Tchobanoglous, G. 42
 More Typical Contaminants Found in Raw Water

Class Groundwater Surface water

Organic compounds,
Dissolved Fe, Mn, hardness ions, inorganic
tannic acids, harness ions,
materials salts, trace organic compounds
inorganic salts

Dissolved gases Carbon dioxide, hydrogen sulfide

Immiscible liquids Oils and greases

Source: Tchobanoglous, G. 43
Simplified Flowchart of Drinking Water Treatment

DRINKING WATER SOURCE (RAW WATER)

COAGULATION, THEN FLOCCULATION

Chemical treatment to form floc,
which is allowed to settle from water

SEDIMENTATION

FILTRATION
To remove remaining solids

DISINFECTION
Chlorine to kill microorganisms

DISTRIBUTION SYSTEM
44
Water Disinfection Requirements
„ Must destroy bacteria, viruses, and amebic cysts in water
within a reasonable time despite all variations in water
temperature, composition, and concentration of
contaminants
„ Must not be toxic for humans and domestic animals,
unpalatable, or otherwise objectionable

45
Water Disinfection Requirements
„ Must be reasonable in cost and safe and easy to store,
transport, handle, and apply
„ Residual concentration in the treated water must be easily
and, preferably, automatically determinable
„ Must be sufficiently persistent so that the disappearance of
the residual would be a warning of contamination

46
 Chlorine

Chlorine is the
favored disinfectant
for water supplies
Chlorine
kills microorganisms

Chlorine Remaining
reacts with chlorine, termed
ammonia and “free,” is available
other to disinfect any
substances new input of
microorganisms

Source: ReVelle, P.
47
Inactivation Curves of Microorganisms
„ Inactivation curves of microorganisms following disinfection

100
A. Sensitive homogeneous population
B. More resistant homogeneous population
Percent survival

C. Heterogeneous population or one partially

protected by aggregation

A B C
0
Time
48
Microbial Inactivation by Chlorine
„ Microbial inactivation by chlorine (99.9% of organisms killed)

Chlorine concentration Inactivation time Ct

(mg/L) (minutes) (concentration x time)

0.5 1.0 0.5

1.0 0.5 0.5

2.0 0.25 0.5

The organism, temperature and pH are the same

49
 Microbial Inactivation by Chlorine: Ct Values*

Chlorine Inactivation time

Microorganism Ct
Conc., mg/L (minutes)
E. coli 0.1 0.4 0.04

Poliovirus 1.0 1.7 1.7

E. histolytica cysts 5.0 18 90

G. lamblia cysts 5.5 100 250

Cryptosporidium >250

*99.9% kill; Temp. - 5oC; pH = 6.0

Source: Bitton, G.
50
 The Shortcomings of Chlorine
„ Chlorine does not kill protozoan cysts and some resistant
viruses

Raw sewage

Treated sewage

Rivers
Rivers and&streams
streams

Reservoirs and&lakes
Reservoirs lakes

Pristine surface water

Drinking water

0 20 40 60 80 100
Percent of samples positive for oocysts
Source: McFeters, G. A.
51
Chlorine Reaction Products
„ Chlorination has the potential of reacting with some organic
compounds present in the water supply to create
trihalomethanes (THM; chloroform)
„ Surface water supplies, high in dissolved natural organic
material (humics), are especially vulnerable to THM formation

52
Chlorine Reaction Products
„ When free chlorine is the disinfectant, THM levels are
generally higher in communities using rivers and streams as
their source of drinking water than in communities using
wells
„ THMs are potentially carcinogenic

53
Activities Permitted for Various Coliform Levels
„ Activities permitted for various levels of coliform bacteria in
water

Coliform level per

Activity permitted
100 ml of water

1 coliform or fewer Water safe for drinking

State must be notified and corrective

4 coliforms or more
measures taken

2,300 coliforms or fewer Swimming is allowed

10,000 coliforms or fewer Boating is allowed

54
Section C

Wastewater
Wastewater Components of Concern

Wastewater components of concern

Nutrients
Pathogens BOD*
(N and P)

Suspended Toxic
solids chemicals

*Biological oxygen demand (oxygen-demanding substances)

56
Some Primary Constituents of Municipal Sewage

Constituents Potential sources Effects in water

Oxygen-demanding Organic material

Consumes dissolved O2
substances (human feces)

Pathogens Human waste Cause disease

Nutrients Detergents Algal nutrients

Toxic chemicals Industrial waste Toxicity

Interferes with
Suspended solids Silt
disinfection

57
 Enteric Organisms in U.S. Surface Water and Sewage
„ Estimated levels of enteric organisms in U.S. sewage and
polluted surface water—concentration per 100 ml

Polluted stream
Organism Raw sewage
water
Coliforms 109 105

Enteric viruses 102 1–10

Giardia 10 0.1–1

Cryptosporidium 10–103 0.1–102

Source: Pepper, I. L. 58
Biological Oxygen Demand (BOD5)
„ Organic decomposition requires oxygen
„ BOD is defined as the amount of oxygen used by organisms in
a body of water to carry out decomposition
„ The amount of oxygen utilized by microorganisms to oxidize
organic compounds in the dark at 20ºC in 5 days (BOD5)
„ CH2O + O2 H2O + CO2
bacteria

59
Biological Oxygen Demand (BOD5)
„ When bacteria act upon organic matter in sewage, large
amounts of dissolved oxygen are rapidly used up; this can
result in fish kills and drastic alterations of the aquatic
environment
„ BOD is an indication of how much putrecible organic material
is present in the water, with low BOD indicating good water
quality, and high BOD reflecting polluted conditions

60
BOD5 of Selected Waters

Water source BOD5 (mg/L)

Domestic sewage
Raw 300
Treated 10
Textile dying 600
Dairy wastewater 900
Tannery wastewater 1,270
Slaughterhouse wastewater 2,000
Rubber factory 3,300
Distillery vinasse 30,000
Swine lagoon 800
Open feedlot runoff 1,000
Raw swine manure 50,000
61
Why Are Nitrates and Phosphates Pollutants?
„ Eutrophication
− Premature aging of an aquatic system
− Excessive nutrient level and subsequent excessive growth
of algae eventually fills up a lake and transforms it into a
marsh or a bog
„ Source
− Domestic sewage and animal sewage, fertilizer runoff,
detergent (P)
„ Effect on dinoflaggelates (Pfiesteria)
− Fishkills

62
Simplified Flowchart of Wastewater Treatment
Wastewater
Primary
Pretreatment Grit
Physical methods to remove solid materials

Sedimentation
Suspended solids allowed to settle Primary
Secondary sludge
BIOLOGICAL TREATMENT
Uses microorganisms to digest soluble substances

Secondary
SEDIMENTATION
sludge
Tertiary
SPECIALIZED TREATMENT
Removes phosphorus and nitrogen

DISINFECTION

DISCHARGE OF EFFLUENTS TO RECEIVING STREAM 63

Municipal Sewage Treatment
„ The aim of sewage treatment is to improve the quality of
wastewater to the point that it can be discharged into a
waterway without seriously disrupting the aquatic
environment or causing human health problems in the form
of waterborne disease

64
Municipal Sewage Treatment
„ With few exceptions, water purification and wastewater
treatment processes are alike in concept and in kind
− They differ only in the amount of pollutants they must
remove and in the degree of purification they must
accomplish

65
Municipal Sewage Treatment: Primary Treatment
„ Primary treatment consists of simply holding sewage in a
large tank to permit the removal of solids by sedimentation
− Before entering the settling tank, the sewage is
commonly sent through a chamber or collector to
remove sand, grit, and small rocks that would otherwise
damage pumps or other equipment in the treatment
plant

66
Municipal Sewage Treatment: Secondary Treatment
„ Whereas primary treatment is based upon physical and
mechanical methods of removing suspended solids from
wastewater, secondary treatment depends on biological
processes—similar to naturally occurring decomposition, but
greatly accelerated—to digest organic waste

67
Municipal Sewage Treatment: Tertiary Treatment
„ Tertiary treatment, if done, removes nutrients such as
nitrogen and phosphorus

68
Municipal Sewage Treatment: Disinfection
„ Disinfection: Since most waterborne diseases are caused by
pathogenic bacteria, viruses, or protozoans present in human
excrement, one of the primary purposes of sewage treatment
is to kill such organisms before they can infect new victims

69
Municipal Sewage Treatment: Disinfection
„ Disinfection: Primary and secondary treatment leave a
substantial number of live organisms still remaining in the
wastewater
− Therefore, it has been standard procedure for many years
to disinfect treated effluent by adding chlorine prior to
discharge in order to eliminate any remaining disease-
causing organisms

70
Municipal Sewage Treatment: Chlorination
„ More recently, the policy of chlorinating all sewage treatment
plant discharges has met with increasing resistance and
today more than half of all states no longer require
chlorination of wastewater

71
Municipal Sewage Treatment: Chlorination
„ There are several reasons for this change in accepted practice
− Chlorine is effective in killing bacteria but less so in
relation to protozoans and viruses
− Chloramines are formed which may be toxic to aquatic
life
− Chlorine treatment is expensive

72
 Removal of Contaminants by Sewage Treatment

Phosphorus

Viruses and
protozoans
Pathogenic
Dissolved

Nitrogen
organics

bacteria
Sewage
solids
Primary
treatment

Secondary
treatment

Tertiary
treatment

Disinfection

Still
Source: ReVelle, P. detectable 73
 Waterborne Outbreaks (U.S.)
waterborne disease outbreaks

40
Average annual number of

30

20

10

1938– 1941– 1946– 1951– 1956– 1961– 1966– 1971– 1976– 1980–
1940 1945 1950 1955 1960 1965 1970 1975 1980 1985

Source: Gabler, R. 74
 Outbreaks by Public Water System Deficiencies
„ Percentage distribution of waterborne disease outbreaks
caused by deficiencies in public water systems

Distribution
network problems
21%
Miscellaneous
9%

Contaminated
untreated surface water
Inadequate
8%
or interrupted
treatment
27%

Contaminated
untreated groundwater
35%
Source: Bitton, G. 75
 Agents Associated with Cases of Waterborne Diseases
„ Etiologic agents associated with cases of waterborne diseases

Bacterial
10%
Acute gastro-
Giardia
intestinal illness of
11%
unknown origin (AGI)
43%

Viral AGI
15%

Cryptosporidium
Source: Pepper, I. L.
20% 76
 Classification of Water-Related Illnesses
„ Classification of water-related illnesses associated with
microorganisms
Class Cause Examples
Pathogens that originate in fecal Cholerae, giardiasis,
Waterborne
material and are transmitted by salmomellosis, poliomyelitis,
(fecal-oral)
ingestion typhoid, E. coli

Pathogens that originate in feces

Infectious eye and skin diseases,
and are transmitted through
Watershed louse-borne typhus and
contact because of inadequate
relapsing fever
sanitation or hygiene

Organisms that originate in water

Water-based
Water-related insect vector
or spend part of their life cycle in Schistosomiasis, dracunculiasis
water and come in direct contact (helminths)
with humans in water
Microorganisms with life cycles
Malaria, yellow fever, dengue
associated with insects that live or
fever, filariasis
breed in water

77
Key Points
„ The hydrological cycle controls the availability of freshwater,
which is diminishing
„ Groundwater and surface water are polluted by both point
and nonpoint sources
„ Water purification is used to provide potable water; chlorine
is the favored disinfectant
„ Wastewater treatment must address pathogens, suspended
solids, toxins, nitrogen and phosphorus, and BOD

78
Key Points
„ Microbial contamination represents the greatest food hazards
„ The extent and magnitude of foodborne disease outbreaks
are largely underestimated
„ Microbial growth in food depends on nutrient availability,
moisture content, redox potential, temperature, and pH
„ Host susceptibility factors are an important determinant in
foodborne diseases
„ Food preservation is used to prolong shelf life

79