Cholera in Portugal 1974 2467 hospitalised cases and 48 deaths

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Bottled water
Gordon Nichols Gastrointestinal, Emerging and
Zoonotic Infections Department HPA Centre for
Infections 61, Colindale Avenue, London NW9
5EQ gordon.nichols_at_hpa.org.uk
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Bottled water

• Mineral water
• Spring water
• Bottled water
• Water dispensers

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Cholera in Portugal 19742467 hospitalised cases
and 48 deaths
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Cholera cases in Lisbon 1974

• Total cases in Lisbon
• Cases known to have consumed bottled water,
  visited the spa or worked at the spa within 5
  days of symptoms

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Salmonella Bareilly, USA 2000

• Multi-state outbreak April-August.
• 84 persons affected.
• Associated with drinking bottled water (spring
  water or infant water) or with water from a
  linked private well or spring.
• Water treated by filtration, UV and ozonization,
  but E.coli and coliforms detected in some samples
  suggesting poor application of treatment.
• MMWR 200251SS1-28

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Campylobacter jejuni,USA 1997

• 106 soldiers became ill after a training exercise
  in Greece
• Greek bottled water identified as the source
• No further information available
• MMWR 200049SS4 1-21.

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Vibrio cholerae non O1, Saipan, Northern Mariana
Island 1994

• 11 patients infected
• 4 hospitalised
• Public tap water is too salty to drink
• General use of bottled reverse osmosis treated
  municipal water
• Multi-use bottles
• Hot water and chlorine cleaning
• Coliforms detected in bottled water
• poor cleaning of returned bottles suspected
• MMWR 199645SS1-33.

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Natural Mineral Water Microbiological analysis
must include

• a demonstration of the absence of parasites and
  pathogenic organisms, quantitative determination
  of the indicators of faecal contamination,
  showing
• absence of Escherichia coli and other coliforms
  in 250 ml,
• absence of faecal streptococci in 250 ml,
• absence of sporulated sulphite-reducing anaerobes
  in 50 ml and
• absence of Pseudomonas aeruginosa in 250 ml.
• determination of total viable colony count per
  millilitre of water at 20-22 C in 72 hours on
  agar-agar or agar-gelatine mixture and at 37 C
  in 24 hours on agar-agar.
• It may be necessary to carry out analysis of
  parasites (Giardia, Cryptosporidium, parasitic
  helminths, amoebae) and pathogens (Salmonella
  spp., Shigella spp., Aeromonas hydrophila spp.
  and Vibrio spp.) in specified volumes of water at
  not less than six monthly intervals over two
  years.
• Quantitative determination of the indicators of
  faecal contamination (E. coli and other
  coliforms) should be carried out at least every
  month for two years. The total viable count
  should be measured every month for two years and
  should be no higher than normally observed (i.e.
  there should be no evidence of occasional
  contamination).

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Natural Mineral Waters
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Spring, Bottled and Dispenser Waters
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Bacteria found in Bottled water

• Acinetobacter junii
• Burkholderia cepacia
• CDC gr.IVC-2d
• Commamonas sp.
• Flavobacterium oryzahabitans
• Moraxella sp.
• Sphaeromonas paucimobilis
• Staphylococcus spp.
• Ralstonia pikettii
• Stenotrophomonas maltophilia

Pseudomonas acidovorans Pseudomonas
aeruginosa Pseudomonas alcaligenes Pseudomonas
diminuta Pseudomonas fluorescens Pseudomonas
mesophilica Pseudomonas paucimobilis Pseudomonas
pseudalcaligines Pseudomonas putida Pseudomonas
stutzeri Pseudomonas vesicularis

• Benito et al, 1999. Int J Food Micro
• Hernandz-Duquino Rosenberg, 1987 Can J Micro
• Hunter 1993 J Appl Micro
• Manaia et al, 1990 J Appl Bact

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Growth of bacteria in bottled water

• PCA diluted ¼ and 1/10
• Few qualitative or quantitative differences
  between counts at purchase and after 6 months at
  room temperature

• Benito et al, 1999. Int J Food Micro
• Hernandz-Duquino Rosenberg, 1987 Can J Micro
• Hunter 1993 J Appl Micro
• Manaia et al, 1990 J Appl Bact

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Survival of Escherichia coli O157 in natural
mineral water (NMW), Sterile mineral water (SMW)
and sterile distilled deionised water (SDW)
(Kerr et al, 1999 J Appl Micro)
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Effect of Escherichia coli O157 added to natural
mineral water (NMW) on the autochthnonous
flora(Kerr et al, 1999 J Appl Micro)
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Growth kinetics of Pseudomonas aeruginosa in
bottled waterTamagnini Gonzalez 1997

• Counts of Ps aeruginosa increased to between 103
  and 106/ml within 6 days of bottling
• Doubling time 26 hours with accompanying flora
• Doubling time of 3.6 hours in sterile water

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Protozoa

• Naegleria gruberi
• Acanthamoeba astronyxis
• Valkampfia valkampfi
• Bodomorpha minima
• Cryptosporidium spp.
• Giardia spp.

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Algae

• Green
• Actinastrum
• Ankistrodesmus
• Staurastrum
• Eudorina
• Oocystis
• Scenedesmus
• Tetraedron

• Blue-green
• Agmenellum
• Anabena
• Cylindrospermum

• Diatoms
• Bacillaria
• Cyclotella
• Melosira
• Synedra

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Microcystis aeruginosa
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Viruses

• A group in Switzerland has reported the detection
  of Norwalk-like viruses (NLVs) in mineral waters
  (Beuret et al. 2000 and Beuret et al. 2002)
• The first described the detection of NLV in 21 x
  1.5 litre samples of 69 mineral waters from 11
  out of 29 different brands
• The second reported detecting NLV in 53 out of
  159 samples tested from 3 brands and
  contamination was confirmed by testing further
  samples from positive batches. Waters were
  either imported into Switzerland or bottled there
  
• One-litre and 0.1-litre volumes of water were
  tested. All positives occurred in the one-litre
  volumes.
• It is likely that non-viable virus sequences were
  detected

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Campylobacter spp.

• Outbreaks tend to be small
• Outbreaks associated with private water supplies
• Seasonal changes in incidence
• Continuing increase in cases
• Epidemiology remains unclear
• Case case association between Campylobacter and
  bottled water (Evans et al, 2003)

• Virginia-Maryland Regional College of Veterinary
  Medicine, Blacksburg, Virginia.

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Outbreaks linked to private water supplies
1970-2004

• 32 outbreaks
• Campylobacter (13)
• Cryptosporidium (3)
• Cryptosporidium and Campylobacter (2)
• Campylobacter E. coli O157 (1)
• Giardia (1)
• E.coli O157 (3)
• Norovirus (1)
• Streptobacillus (1)
• Salmonella paratyphi B (1)
• Not known (6)

Said B, Wright F, Nichols GL, Reacher M, Rutter
M. Outbreaks of infectious disease associated
with private drinking water supplies in England
and Wales 1970-2000. Epidemiol Infect. 2003
Jun130(3)469-79.Yip, H. Risk Assessment of
Private Water supplies. PhD Thesis 2007
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Water use in the home

• Greater use of end point treatment devices
• Dissatisfaction with chlorine residual and
  hardness
• Increased water storage in the kitchen
• Increased consumption of bottled water
• Increased risk of cross contamination in the
  kitchen

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Public and private water supply telephone survey
Overview

• Interview success rate 46 (317 / 687)
• Water supplies
• 61 Private supply (19)
• 254 Mains supply (80)
• 2 Both private and mains (1)
• Key finding
• Private water supply users are happier with their
  drinking water than mains water users (Private
  95, Mains 76)
• Reasons why people like their water
• TASTE
• Reasons why people dont like their water TASTE
  CHEMICAL (especially Chlorine)
• People on mains supplies drink more bottled water
  (31) than people on private supplies (16).

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Conclusions

• Bottled water is a safe product
• Main risk is from faecal contamination of the
  source
• Escherichia coli and enterococci are the
  important indicators
• Risk assessment linked to monitoring is a safe
  means of control