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Dispatches Burkholderia pseudomallei Traced to Water Treatment Plant in AustraliaTimothy J.J. Inglis,* Stuart C. Garrow, Mandy Henderson,*
Adele Clair,* Judy Sampson,* Lyn O'Reilly,* and Bob Cameron
Melioidosis is endemic in northern Australia. Since the first description of the disease from far north Queensland in 1962 (1), melioidosis has spread west and south. A small focus of endemic infection was identified in western Australia in 1967 (2). Cases are reported throughout the year but peak during the rainy season (3). An unusually large number of cases was diagnosed in the Northern Territory during the near-record rainfall of 1990-91 (4). A cluster of acute melioidosis cases in a remote, coastal community (population 300) in western Australia during the dry season in late 1997 was, therefore, unexpected (5). Five cases of acute septicemic or pneumonic melioidosis were diagnosed during a 6-week period. All five patients lived in the same remote community and had recognized risk factors for acute melioidosis (e.g., diabetes or renal failure). Burkholderia pseudomallei was isolated from all patients; three died. Late-onset septicemia was diagnosed in a resident of this community 6 months later. This infection was preceded by a febrile episode during the presumed exposure period and soft tissue infection 1 month later. All six isolates were indistinguishable by pulsed-field gel electrophoresis (PFGE). Environmental sampling during the outbreak investigation identified the potable water supply as a possible source of B. pseudomallei. Epidemiologic investigations implicated acid bore water, chlorination failure, recent replacement of water pipes, and climate. Twelve months later, after maintenance work on the water supply was completed, microbiologic samples were collected again. Isolation of B. pseudomallei prompted a more detailed environmental investigation with emphasis on the water treatment plant and bore water. The water supply to the community comes from a subterranean source through a group of capped and sealed bore holes. These are fed by an underground common bore main into the water treatment compound, where the bore water is passed through an aerator tower, then stored in two ground-level tanks before chlorination. After passing through a gas chlorinator, water is fed through another underground main pipe to the community, is pumped up into a high-level tank, and flows into the underground domestic reticulation system. Outlets in family dwellings and community buildings are plumbed faucets, showerheads, and water closets. Potable water is supplied to the community at a rate of approximately 500 kL per day. Preliminary BacteriologyWe collected a 5-L water specimen from the previously culture-positive yard tap and another 5-L specimen from the sample access point before the gas chlorinator unit, after flame-sterilizing the outlet and letting water run for a prolonged period. A clump of wild grass above the bore line entering the compound, near the place where an excavator punctured the pipeline, was dug up with its roots intact. Water specimens were filtered, and the filter membrane was cultured in Ashdown broth and subcultured onto Ashdown agar. A 5-g sample of root soil was suspended in sterile saline and processed as for water specimens. Suspect colonies were identified by standard laboratory methods and confirmed by polymerase chain reaction (PCR) amplification of B. pseudomallei DNA sequences (6). B. pseudomallei was isolated from all three tested specimens, although the species was recovered only from the tap water after enrichment with trypticase soy broth and prolonged incubation (2 weeks). Sediment from the bottom of the water tank and a 5-L specimen of tank contents were cultured. Both were positive for B. pseudomallei. |
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Burkholderia |
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Sample |
pseudomallei |
WKo97 |
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All bores |
- |
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Bore line root soil |
+ |
- |
Acacia root soil |
+ |
- |
Aerator |
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Upper spray |
+ |
+ |
Lower spray |
+ |
+ |
Tray biofilm |
- |
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Sump water |
- |
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Sump biofilm |
- |
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Storage tank |
||
Surface water |
- |
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Deep water |
+ |
+ |
Sediment |
+ |
+ |
Prechlorinator |
- |
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Postchlorinator |
- |
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High-level tank |
- |
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Domestic tap water |
- |
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Backyard tap |
+ |
- |
Storage tank repeat |
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Deep water |
- |
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Figure | ||
Click to view enlarged
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Environmental and clinical isolates of B. pseudomallei were typed by PFGE of an XbaI restriction digest of bacterial chromosomal DNA (Figure). After completion of these studies, environmental isolates from parts of the potable water supply, nearby soil, and two distant locations (250 and 1,000 km away) were run simultaneously with human and animal clinical isolates. As two gels were required, clinical isolates were run on one gel with a duplicate of the initial tap water isolate, and environmental isolates were run with a duplicated digest from the fifth case in the cluster. Soil isolates were distinct from the outbreak strain, but the aerator spray and ground tank isolates were identical to the outbreak strain, WKo97 (Figure; Table).
Confirmation that a specific device in the water treatment plant had become heavily contaminated with B. pseudomallei prompted biocontainment questions. Arrangements were made to isolate the aerator from the water inflow, dismantle it, and remove its parts for incineration. Before being dismantled, the aerator was drained and soaked in concentrated hypochlorite, then wrapped in a polythene sheet. Workers wore submicron particle filter masks, protective overalls, and heavy-duty gloves. The ground-level tank was drained, treated with concentrated hypochlorite solution, and cleaned before refilling. Samples collected from the ground-level tank 2 months after these measures had been completed contained no detectable B. pseudomallei.
In our investigation of the persistence of B. pseudomallei in the potable water supply, we traced the source of contamination upstream to the water treatment plant and identified the aerator as a possible source. If it had been connected during the initial outbreak investigation and had been sampled then, the aerator might have been identified as a potential source 1 year earlier. Moreover, failure to fully digest the prechlorination isolate in this and a second reference laboratory led to the erroneous belief that the prechlorination point result was unrelated to the case-cluster. We cannot prove beyond doubt that the aerator was the primary source of contamination without contemporaneous bacteriologic evidence. It is unlikely the aerator became contaminated later as a result of retrograde flow, especially from a point downstream to the chlorinator unit. There are thus several possible sources of contamination: inflowing water from a leak in the bore pipeline, rupture of the pipeline during renovation work, dust or vegetation blown through the mesh walls of the aerator by wind, or direct contact with contaminated soil during refurbishment of the dismantled aerator. The 1997 outbreak may have occurred because a shower of bacteria was released from the aerator into the potable water supply during renovation work on the aerator at a time when chlorine levels were at or near zero. The aerator unit had only a modest effect on pH but clearly provided optimal conditions for multiplication of aquatic bacteria with an aerobic metabolism (7). Whether or not the aerator became contaminated more recently than the outbreak, its ability to act as a persistent source or amplifier of the outbreak strain of B. pseudomallei justified its removal.
Aerators are used to correct acidic, ferric, or unusually warm potable groundwater supplies in many remote communities in northern Australia and represent a potential melioidosis risk. Deliberate or natural aeration of a contaminated water supply could amplify B. pseudomallei growth. In northeastern Thailand, where melioidosis is endemic and the groundwater is unusually acidic (8), natural or artificial aeration of the potable water supply should be considered as an additional contributory factor.
Measures taken after the initial western Australian outbreak investigation appear to have prevented further cases, despite the presence of multiple B. pseudomallei types in soil. Initial water engineering measures have cleared detectable B. pseudomallei from the water treatment plant.
Permission to publish this report was granted by the community council. We thank Nicky Buller and the Agriculture Department of Western Australia for supplying the animal and related environmental strains of B. pseudomallei and David Dance and Thomas Riley for reviewing the manuscript.
Dr. Inglis is a medical microbiologist at PathCentre, the Western Australian Centre for Pathology and Medical Research. His duties include public health microbiology and hospital infection control. Other than melioidosis, current research interests include the laboratory-based surveillance of infectious disease and the pathogenesis of ventilator-associated pneumonia.
Address for correspondence: Timothy J.J. Inglis, Division of Microbiology and Infectious Diseases, PathCentre, Locked Bag 2009, Nedlands, WA 6009, Australia; fax: 619-9381-7139; e-mail: tim.inglis@health.wa.gov.au
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