Module

1.3
1.3 Water Epidemiology & Microbiology
Epidemiology – the study of the incidence and distribution of diseases and
of their control and prevention

Microbiology – the study of micro-organisms e.g. bacteria, viruses, fungi

and protozoa

Giardia Helminths

Absolutely pure water is very

rare. Contaminants of all sorts
are present in every source of
water and some of them, such as
minerals, are essential for life,
while others can be very deadly
even in small portions. Disease
causing germs called pathogens
are undesirable contaminants
that have to be removed to ensure
safe potable water. This module
Cryptosporidium describes water related diseases
and the pathogens that cause
them.
Module 1.3 Water Epidemiology and Microbiology

1.3 WATER EPIDEMIOLOGY & MICROBIOLOGY..............................................................................1

GLOBAL IMPACT ...............................................................................................................................................2
WATER RELATED DISEASES................................................................................................................................3
PATHOGENS .....................................................................................................................................................4
BACTERIA .......................................................................................................................................................5
VIRUSES..........................................................................................................................................................7
PROTOZOA........................................................................................................................................................8
HELMINTHS......................................................................................................................................................9
DISEASE TRANSMISSION...................................................................................................................................11
Minimum Infectious Dose.......................................................................................................................11
WATER BORNE - ARSENIC................................................................................................................................13

Global Impact
The World Health Organization said in a report on water and sanitation, released to mark
World Water Day, that more than one billion people drink unsafe water. Some 3.4
million people, mostly children, die every year from water-related diseases, which
include malaria, diarrhoea and guinea worm.

• Over half experience more than

fifteen attacks of serious diarrhoea
before the age of five. (Bern 1992).
• Diarrhoea inhibits the ability of the
body to absorb nutrition.
• Children become at risk of stunting
from malnutrition (Gadgil 98).
• Children cannot wash often enough
and so suffer from eye infections and
skin diseases such as scabies.

• Over 5 million children die every

year from diarrhoeal disease and
dehydration (WHO 98)

Page 2 of 14
Almost two thirds of child deaths each year are accounted for by just five specific causes;
diarrhoea, acute respiratory infections, measles, malaria and perinatal.

Distribution of 11.6 million deaths among children

less than 5 years old in all developing countries (1995)

* For the purposes of this

chart, one cause has been
allocated for each child
death. In practice, children
often die of multiple causes
and malnutrition is a
contributory cause in
approximately one third of
all child deaths.

http://www.rehydrate.org/facts/
child_deaths.htm (Apr 05)

Water Related Diseases

Water related diseases can be divided into two categories – microbial contamination and
chemical contamination. In most cases, microbial contamination is more common, with
more severe consequences, and is responsible for the majority of the disease burden such
as sickness and death.

The majority of human diseases associated with microbial contaminated water are
infectious in nature. They can be categorized based on the source of the pathogen and the
route by which human recipients contact the pathogen.
• Waterborne infections result primarily from ingestion of contaminated water. –
depends on quality of water consumed, most cause diarrhoea, cholera, typhoid and
hepatitis - Intervention: must remove or kill agents
• Water washed infections are acquired by contact with microbial contaminated
material e.g. faeces. – Insufficient water for bathing, infection of the skin, eyes or
intestinal tract – shigellosis, skin sepsis, scabies, fungal infections – Intervention:
increase the quantity of water as well as quality.
• Water based infections are caused by pathogenic worms which must spend part of
their life cycle in hosts that reside in aquatic environments. Diseases are acquired by
physical contact or inadvertent ingestion. – parasitic worms, burrowing into the
skin of host from infected water, Schistosomiasis, guinea worm – Intervention: reduce
contact with infected water and remove worms from water
• Water related diseases are not acquired from water but rather from vectors, usually
mosquitoes, whose life cycles depend on access to water. – malaria, dengue, yellow
fever; black fly - river blindness; tsetse fly – sleeping sickness; - Intervention:
make water inaccessible, control insects, prevent insects from biting

Extent of Water Related Disease

Disease Type Morbidity (illness) Mortality (death)
Faecal-Oral
Diarrhoeal 1000 Million episodes/year 3.3 Million
Cholera >300,000 >3000
Enteric Fevers >500,000 >25,000
Roundworm 20-40% rate of infection
Water Washed
Trachoma 6-9 Million Blind
Skin Infections Millions
Water Based
Shistosomiasis 200 Million >200,000
Guinea Worm 35,000 and dropping
Insect Vector
Malaria 300-500 Million 1.5-1.7 Million
Filiariasis 128 Million
Dengue 30-60 Million infected/year

Pathogens
Pathogens, or disease causing organisms, can be broken into four main categories:

 Bacteria – smallest wholly contained living organism, most dominant pathogen

 Virus – smallest & most complex, but requires host cell
 Protozoa – single celled organism, may be able to form cysts
 Helminth / Worm – multicellular parasite, derives sustenance at host’s expense

The following are typical sizes of various pathogens:

Bacteria: 0.2 – 5 microns

Viruses: 0.02 – 0.2 microns
Protozoa: 4 – 20 microns
Helminth: 40 – 100 microns

These relative sizes are important when discussing filtration and the size of particles that can be
filtered out of a water stream.
This animation shows the size of bacteria and viruses relative to other objects.
http://www.cellsalive.com/howbig.htm (Apr 05)

Bacteria
Bacteria dominate the living organisms found in faeces. They are the simplest, wholly
contained life systems and are the most diverse group of micro organisms. Like all living
creatures, they require an energy source and a carbon source in order to survive.

Some common bacterial agents of disease are given below although this list is by no
means complete.

Bacterial Infectious Agents

Potentially Present in Raw Domestic Wastewater
Organism Disease Symptoms Persistence in
Water Supplies
Escherichia coli Gastroenteritis Diarrhoea Moderate
Legionella Legionellosis Acute respiratory illness
pneumophila
Leptospira (150spp.) Leptospirosis Jaundice, fever (Well’s
disease)
Salmonella typhi Typhoid fever High fever, diarrhoea, Moderate
ulceration of small intestine
Salmonella Salmonellosis Food poisoning Moderate
(~1700spp.)
Shigella (4spp.) Shigellosis Bacillary Dysentery Short
Vibrio Cholerae Cholera Extremely heavy diarrhoea, Short
dehydration
Yersinia enterolitica Yersinosis Diarrhoea Long
Source: Metcalf and Eddy Inc. as revised by Tchobanoglous and Burton. 1991

Many of these bacteria cause diarrhoea or dysentery, which is a more severe upset of the
digestive system involving inflammation of the stomach and intestinal linings.

Vibrio Cholerae and Salmonella Typhi were the first waterborne pathogens to be
recognized. Identified in the 19th century, they have been responsible for tremendous
morbidity and mortality.

Cholera is one of the most well-known and widely feared water borne diseases. The
microbial agent, Vibrio Cholerae, produces a substance that affects the isotonic balance
in the fluids in the digestive system causing excessive fluid loss. Death can occur in three
to twelve hours. There is no vaccine that imparts any lasting immunity. Vibrio cholerae
and other vibrios are quite hardy and are able to persist in demanding environments.
E. Coli - Coliforms

E. coli may be a common term to some people because of news stories. It is actually the
abbreviated name for the bacterium, which, according to the scientific classification system,
belongs to the Enterobacteriaceae family, the Escherichia genus, and the Coli species, or E.
coli for short.

About one in every thousand bacteria found in an adult's intestines is E. coli. But in a newborn
baby's intestines this type of bacteria is more abundant, as are other bacteria like lactobacilli
and enterococci. E. coli form part of a group of rod-shaped bacteria known as coliform
organisms.

They are important in water quality testing because simple means to detect their presence in the
water have been developed over the years. Their presence in water is taken as an indication that
the water has been contaminated with human or animal waste.

Generally it is healthy to have coliforms and other kinds of bacteria in our intestines. They help
us digest our food. For example, the bacteria E. coli in our intestines are a source of Vitamin K
and B-complex vitamins. We are never without these bacteria, which is good because they keep
us healthy. There are about as many bacteria in your intestine as there are people on the entire
earth, 5.5 to 6 billion of them. They also reproduce very fast in our intestines.

Each person discharges from 100 to 400 billion coliforms every day. Coliform bacteria are
therefore very numerous and are also easier to detect than pathogenic (disease-causing) micro
organisms.

The water does not have to be ingested in all cases to cause disease. Legionella
pneumophila, for example, live naturally in lakes and rivers and can readily colonize
water distribution systems or home heating units. The mode of infection appears to be
inhalation of infected aerosols.
Additionally, the agents do not need to be alive when ingested to cause disease. In the
case of salmonella, food containing the bacteria provides a suitable environment for the
bacteria to multiply and produce their toxins. When the food is eaten, the person suffers
from the effects of the toxins.

Viruses
Viruses are the smallest disease causing agents. Moreover, virology is more complex and
costly than bacteriology. Consequently, knowledge of viruses is not as refined as for
other pathogens. Viruses are unable to replicate by themselves and must invade a host
cell to use the cell’s machinery to make more viruses. This disrupts the cell functions or
causes the death of the cell.

Viral Infectious Agents

Potentially Present in Raw Domestic Wastewater

Organism Disease Symptoms/

Remarks

Adenovirus (31 Respiratory disease

types)
Enteroviruses (67 Gastroenteritis, heart
types)e.g. polio, echo anomalies, meningitis
and coxsackie viruses

Hepatitis A Infectious Hepatitis Jaundice, fever

Norwalk agent Gastroenteritis Vomiting

Reovirus Gastroenteritis

Rotavirus Gastroenteritis

( Taken from Metcalf and Eddy Inc. as revised by Tchobanoglous and

Burton. 1991)

Enteric viruses are more recently recognized waterborne pathogens. Inadequate

diagnostic technology has limited the detection of viruses. Many outbreaks reported as
acute and of unknown source are likely due to viral agents.

Viruses transmitted by water usually cause nervous system disorders rather than
diarrhoea. Norwalk-like viruses, a group first identified less than 30 years ago, cause 66%
of illnesses caused by water borne pathogens in the United States.

Viruses generally produce a milder affliction than bacteria. Enteroviruses and reoviruses
are presently considered of only minor importance in the occurrence of water borne
diseases. There is strong evidence, however, that rotaviruses and a variety of other ill
characterized viruses that cause gastroenteritis are spread significantly by water
transmission.

Human Immune Deficiency Viruses (HIV) and viruses causing the common cold are
unable to survive outside the human body for any significant time and their transmission
through water is not of concern.

Protozoa
Protozoa (meaning “first animal”) are single celled organisms and there are a number of
protozoa that cause disease. Some protozoa are able to form cysts, which are vegetative
states that are resistant to harsh environmental environments. Unlike viruses, they can
stay alive without a host. The organism returns to an active state upon reaching
favourable conditions. Reproduction may be through simple cell division (e.g. the
amoeboflagellates) or sexual involving the fusion of organisms in part of the life cycle
(e.g. the apicomplexa).

Protozoan Infectious Agents

Potentially Present in Raw Domestic Wastewater
Organism Disease Symptoms/ Remarks

Balantidium coli Balantidiasis Diarrhoea, dysentery

Cryptosporidium Cryptosporidiosis Diarrhoea

Entamoeba Amoebiasis Prolonged diarrhoea with

histolytica (amoebic bleeding, abscesses of the
dysentery) liver and small intestine)

Giardia Lamblia Giardiasis Mild to severe diarrhoea,

nausea, indigestion
( Taken from Metcalf and Eddy Inc. as revised by Tchobanoglous and
Burton. 1991)

On a worldwide basis, infections of Entamoeba histolytica are most

common. In the United States, however, the most common cause of
dysentery is the result of cysts of Giardia lamblia. Crytosporidium is
a more recent addition to the list and has been identified as the
causative agent in six waterborne disease outbreaks worldwide.
Helminths
Both helminths and protozoa are considered parasites. In contrast to the protozoa,
helminths (worms and flukes) are multicellular with complex reproductive systems and
life cycles involving intermediate hosts for the development of larval stages and a
definitive host for the adult form. Many of these worms can survive in the body for
several years and debilitate their host by deriving their sustenance at the host’s expense.
However, except for Strongyloides, they do not multiply within the human host. Most
helminths are passed in faeces.

Helminthic Infectious Agents

Potentially Present in Raw Domestic Wastewater
Organism Disease Symptoms/Remarks
Ascaris lumbricoides Ascariasis Roundworm infestation
Enterobius vericularis Enterobiasis Pinworm
Fasciola hepatica Fascioliasis Sheep Liver Fluke
Hymenolepsis nana Hymenolepiasis Dwarf tapeworm
Taenia saginata Taeniasis Beef tapeworm
T. solium Taeniasis Pork tapeworm
Trichuris trichiura Trichuriasis Whipworm
(Source: Metcalf and Eddy Inc. as revised by Tchobanoglous and Burton. 1991)

All helminths are relatively large (> 1 mm long); some are very large (> 1 m long). All
have well-developed organ systems and most are active feeders. The body is either
flattened and covered with plasma membrane (flatworms) or cylindrical and covered with
cuticle (roundworms). Some helminths are hermaphrodites; others have separate sexes.

The mode of transmission varies with the type of worm; it may involve ingestion of eggs
or larvae, penetration by larvae, bite of vectors, or ingestion of stages in the meat of
intermediate hosts. Worms are often long-lived.

Guinea Worm Disease

Guinea Worm disease (Dracunculiasis) can be prevented exclusively through water

interventions. The disease is transmitted by drinking water that contains a small crustacean
infected by a parasitic worm. Thus, the principal means of prevention is through ensuring
access to safe sources and by motivating people to use the safe sources exclusively. Significant
progress has been made in the eradication of the disease since the 1980’s.

In several countries (e.g. Pakistan, Kenya, Yemen) the number of cases have been reduced to
zero through the concentrated efforts of governments, multilateral agencies (including
UNICEF) and other agencies and institutions. All remaining endemic countries are in Africa,
and the majority of cases in Sudan

CDC, Guinea Worm Wrap-up No. 89, April 19, 1999

Parasite infections affect millions of people world-wide inflicting considerable human
suffering and economic hardship. Far from declining, many parasite infections are
increasing throughout the world.

The impact of Human Immunodeficiency Virus (HIV) and AIDS has seen the emergence
of "new" opportunistic parasites as well as the increased prevalence of other recognised
types. Climatic changes induced through global warming have aided the spread of many
parasite diseases, whilst starvation and the breakdown in sanitation that accompanies war
have seen the re-emergence of others.

Schistosomiasis

Schistosomiasis (called bilharzia in Africa) is a parasitic disease caused by schistosomes, or

blood flukes. The disease affects over 200 million people in 75 countries.
In the case of schistosomiasis, the intermediate host is a small snail which lives in slow moving
waters. The second stage of the worm larvae escape from the snails into the water and burrow
through human skin, lodging in the blood vessels. Reservoirs, irrigation canals and swamps
provide ideal breeding conditions for the snail. The increase in the prevalence of dams and
irrigation canals in developing countries and the new permanence of the water have led to an
epidemic of schistosomiasis, approaching 100 per cent in some areas.
• Always assume that bodies of freshwater in endemic areas are infested with schistosomes.
Even deep water, far offshore, may be infective, but is usually safer than the shoreline. Salt and
brackish water are safe.
• A history of exposure to infested water is one of the most important elements in the diagnosis
of schistosomiasis. A schistosome antibody assay should be done when stool or urine tests are
negative for eggs.
• High-risk areas for schistosomiasis include the Nile River, the Omo River in Ethiopia, Lake
Victoria, the Tigris and Euphrates rivers, Lake Malawi, Lake Kariba in Zimbabwe and Lake
Volta in Ghana.

http://www.dpd.cdc.gov/DPDx/HTML/Schistosomiasis.htm (Apr 05)

This web site provides some technical reading if you are interested in helminths
http://gsbs.utmb.edu/microbook/ch087.htm (Apr 05)

Disease Transmission
There are five critical elements in the transmission of infectious agents through water.
1. The source of the infectious agent.
2. The specific water related mode of transmission.
3. The specific attributes of the organism that permit survival or multiplication.
4. The infectious dose or virulence factor.
5. Host susceptibility factors.

Minimum Infectious Dose

The infectious dose is the minimum number of organisms required to cause infection.
The mere presence of a micro organism in the water does not always mean that the water
will cause disease in the person drinking this water. The organisms must be ingested in
quantities greater than the infectious dose to cause disease. These infectious
concentrations vary greatly with pathogen type. In general, enteric viruses and protozoa
have low infectious doses, typically between 1 and 100. The observed average infectious
doses for enteric bacteria range from 100 to 1,000,000,000.

Human Infectious Doses of Certain Pathogen Types

Pathogen Type Organism Infectious
Concentration
Bacteria E. Coli 100 to 1,000,000,000
E. Coli 0157: H7 100
Salmonella 1,000,000 to 10,000,000
Cholera Vibrio 100,000,000
Shigella 100
Viruses Enterovirus 1 to 72
Adenovirus, Polio Echovirus, <100
Coxsackie, Hepatitis A, Reovirus
Protozoa Enteric Amoeba 10 to 100
Giardia lamblia 1 to 10
Cryptosporidium Parvum 10 to 30
Helminths Round worm, pin worm < 10
Tapeworm, whipworm, most types
Dwarf Tapeworm < 100

Those at greatest risk of waterborne disease are infants and young children, people who
are debilitated or living under unsanitary conditions, the sick and the elderly. For these
people, the infectious doses are significantly lower than for the general, adult population.

Viruses and cysts can be particularly infectious since as little as one active virus or cyst
has the potential to cause a sickness. Local populations also develop resistance to locally
occurring pathogens over time. This is why ingestion of water can cause disease more
readily in tourists than in the local population

This web site has interesting information on diseases and the vectors that cause them.
http://www.who.int/water_sanitation_health/hygiene/emergencies/em2002chap10.pdf (Apr 05)
Water Borne - Arsenic
Arsenic is a naturally occurring chemical element found in the earth’s crust. Arsenic can
be released to the environment through natural pathways such as weathering reactions,
volcanic emissions, or biological activities. It can also be released to the environment
through human activities such as burning high-arsenic coal, using CCA (chromated
copper arsenic) to preserve wood products, or applying arsenic-containing pesticides to
fields.

Unlike microbial contamination, arsenic is an element that cannot be destroyed or

inactivated. Arsenic must be removed from drinking water sources.

Over 30 countries in the world areas known to be affected by arsenic in their ground
water due to natural origin (as opposed to human pollution). Although the exact reason
for arsenic leaching from the bedrocks/sediments into the groundwater is unknown, it is
believed that it is related to certain hydro chemical and hydro geological conditions in
those aquifers. In south Asia alone, it is estimated that a total of 60 to 100 million people
are exposed to unsafe levels of arsenic. Bangladesh is the most severely affected, where
35-60 million of its 130 million people are exposed to arsenic in their drinking water.

Zheng Gong, MIT department of Civil and Environmental Engineering, August 2005

After drinking arsenic contaminated water for a few years, the initial visible health effect
is melanosis. Melanosis is light or dark spots on the skin, often on the chest, back, or
palm. After melanosis, keratosis and other lesions may occur. Keratosis is hardening
skin bulges on palms and feet. Long-term ingestion of arsenic contaminated water may
lead to lungs, bladder, kidney, skin, liver, and prostate cancer. Arsenic is also known to
cause vascular diseases, neurological effects, and infant developmental defects.

There is currently no effective cure for arsenic poisoning. The only way to prevent
arsenic poisoning is to drink arsenic-free water.

Melanosis on palm Keratosis on palms Keratosis on feet

Reference Sources:

WHO Synthesis Report on Arsenic in Drinking Water (2002).

http://www.who.int/water_sanitation_health/dwq/arsenic3/en/

US Agency for Toxic Substances and Diseases Registry (ATSDR) ToxFAQ for Arsenic. (2005).
http://atsdr1.atsdr.cdc.gov:8080/tfacts2.html

Harvard University. “Harvard Arsenic Project.” (2005)

http://phys4.harvard.edu/%7Ewilson/arsenic/arsenic_project_introduction.html

World Bank. Towards a More Effective Operational Response: Arsenic Contamination of Groundwater in
south and East Asian Countries. Washington. (2005)