Microbial agents associated with waterborne diseases.

Many classes of pathogens excreted in feces are able to initiate waterborne infections. There are bacterial pathogens, including enteric and aquatic bacteria, enteric viruses, and enteric protozoa, which are strongly resistant in the water environment and to most disinfectants. The infection dose of viral and protozoan agents is lower than bacteria, in the range of one to ten infectious units or oocysts. Waterborne outbreaks of bacterial origin (particularly typhoid fever) in the developing countries have declined dramatically from 1900s. Therefore, some early bacterial agents such as Shigella sonnei remains prevalent and new pathogens of fecal origin such as zoonotic C. jejuni and E. coli O157:H7 may contaminate pristine waters through wildlife or domestic animal feces. The common feature of these bacteria is the low inoculum (a few hundred cells) that may trigger disease. The emergence in early 1992 of serotype O139 of V. cholerae with epidemic potential in Southeast Asia suggests that other serotypes than V. cholerae O1 could also getting on epidemic. Some new pathogens include environmental bacteria that are capable of surviving and proliferating in water distribution systems. Other than specific hosts at risk, the general population is refractory to infection with ingested P. aeruginosa. The significance of Aeromonas spp. in drinking water to the occurrence of acute gastroenteritis remains a debatable point and has to be evaluated in further epidemiological studies. Legionella and Mycobacterium avium complex (MAC) are environmental pathogens that have found an ecologic niche in drinking and hot water supplies. Numerous studies have reported Legionnaires' disease caused by L. pneumophila occurring in residential and hospital water supplies. M. avium complex frequently causes disseminated infections in AIDS patients and drinking water has been suggested as a source of infection; in some cases the relationship has been proven. More and more numerous reports show that Helicobacter pylori DNA can be amplified from feces samples of infected patients, which strongly suggests fecal-to-oral transmission. Therefore, it is possible that H. pylori infection is waterbome, but these assumptions need to be substantiated. Giardiasis has become the most common cause of human waterborne disease in the U.S. over the last 30 years. However, as a result of the massive outbreak of waterborne cryptosporidiosis in Milwaukee, Wisconsin, affecting an estimated 403,000 persons, there is increasing interest in the epidemiology and prevention of new infection disease caused by Cryptosporidium spp. as well as monitoring water quality. The transmission of Cryptosporidium and Giardia through treated water supplies that meet water quality standards demonstrates that water treatment technologies have become inadequate, and that a negative coliform no longer guarantees that water is free from all pathogens, especially from protozoan agents. Substantial concern persists that low levels of pathogen occurrence may be responsible for the endemic transmission of enteric disease. In addition to Giardia and Cryptosporidium, some species of genera Cyclospora, Isospora, and of family Microsporidia are emerging as opportunistic pathogens and may have waterborne routes of transmission. More than 15 different groups of viruses, encompassing more than 140 distinct types can be found in the human gut. Some cause illness unrelated with the gut epithelium, such as Hepatitis A virus (HAV) and Hepatitis E virus (HEV). Numerous large outbreaks have been documented in the U.S. between 1950 and 1970, and the incidence rate has strongly declined in developing countries since the 1970s. Hepatitis E is mostly confined to tropical and subtropical areas, but recent reports indicate that it can occur at a low level in Europe. A relatively small group of viruses have been incriminated as causes of acute gastroenteritis in humans and fewer have proven to be true etiologic agents, including rotavirus, calicivirus, astrovirus, and some enteric adenovirus. These enteric viruses have infrequently been identified as the etiologic agents of waterborne disease outbreaks, because of inadequate diagnostic technology, but many outbreaks of unknown etiology currently reported are likely due to viral agents. Actually, Norwalk virus and Norwalk-like viruses are recognized as the major causes of waterborne illnesses world-wide. The global burden of infectious waterborne disease is considerable. Reported numbers highly underestimate the real incidence of waterborne diseases. The most striking concern is that enteric viruses such as caliciviruses and some protozoan agents, such as Cryptosporidium, are the best candidates to reach the highest levels of endemic transmission, because they are ubiquitous in water intended for drinking, being highly resistant to relevant environmental factors, including chemical disinfecting procedures. Other concluding concerns are the enhanced risks for the classic group of debilitated subjects (very young, old, pregnant, and immunocompromised individuals) and the basic requirement of to take specific measures aimed at reducing the risk of waterborne infection diseases in this growing, weaker population.