January-February 2009

Toilet to Tap: Once Again

Indirect potable reuse is assuming a life of its own in the American West. Are we heading in the right direction?

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Photo: Southern California Water Replenishment District

By Penelope B. Grenoble

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Toilet to Tap—with all that’s gone on in the West in the last half-dozen years, from drought to reallocation of Colorado River water, and restrictions coming out of California’s Sacramento Delta, the once-maligned, supply-side strategy seems to be an idea whose time has finally come.

Supposedly attributed to a clever copy editor at the Los Angeles Daily News, “Toilet to Tap” brought down a 33,000-acre-foot groundwater recharge project slated for Los Angeles’ San Fernando Valley, as well as projects in San Diego and Dublin, CA. But the continuing issue for water professionals is that the negative and potentially divisive phase suggests that developing new sources of potable reuse is a simple and capacious undertaking.

In traditional water systems, raw water is diverted from its source in a lake, stream, or aquifer; treated; and distributed, with little more to do. Wastewater is subsequently collected, treated, and discharged to a receiving body. The fact that, in many places in the US, this results in unplanned potable reuse (as the Southern Nevada Water Authority puts it, “borrowing water”) does not in any way diminish the well-developed planned reuse projects emerging in this country.

Planned potable reuse in the US is largely indirect, wherein treated effluent is subject to multiple contaminant-removing barriers, from extensive chemical and physical treatment to dilution and natural cleansing in soil or a body of water. In a 1998 report, the Water Science and Technology Board of the National Research Council’s Commission on Geosciences, Environment, and Resources concluded that, while analytical and toxicological testing, as well as epidemiological studies, have identified no significant health risks in communities using reclaimed water, indirect potable reuse projects should exceed the requirements for conventional water treatment and should employ strong chemical disinfection processes in addition to physical treatment systems. Also, barriers for microbiological contaminants should be more robust than in conventional water treatment.

So, what does it look like out there? Is jumping on the reverse osmosis (RO) bandwagon the way to go? Or is nature perhaps a resource we’ve bypassed in our regulatory zeal? Is it more effective to pull out all the stops before the effluent goes into the ground or treat it as it’s drawn out?

Southern California is served by a complicated mix of city and county utilities, which are in turn regulated by a Byzantine web of agencies, so it might be surprising to learn that Los Angeles has been practicing potable reuse since the 1960s. While Orange County has made a splash with its huge 70-million-gallon-per-day Groundwater Replenishment Project, the Water Replenishment District of Southern California (WRD) has been quietly recharging groundwater with tertiary-treated wastewater, in part with effluent supplied by West Basin Municipal Water District. The WRD’s original rationale was similar to Orange County’s emphasis in its groundbreaking public outreach campaign—protection of natural groundwater by maintaining the barrier that keeps saltwater from contaminating the region’s aquifers. And if some of this water also makes it into raw supplies used for drinking water, well, so be it.

Over the years, WRD has used a mix of treated effluent, stormwater running off the San Gabriel Mountains, and potable water supplied by the Metropolitan Water District of Southern California to recharge the Central and West Basin aquifers, two of the most heavily used groundwater basins in California, serving four million Los Angeles County residents.

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Recurrent drought convinced various powers-that-be that neither nature nor the Metropolitan Water District was reliable enough to keep the aquifers and the sea barriers supplied, and, in 1995, West Basin christened its own advanced water treatment plant. Today, it produces what it describes as five distinctive grades of “designer” recycled water: tertiary, nitrified tertiary (with the ammonia removed for use in industrial cooling towers), softened RO (secondary treated wastewater pretreated by either lime clarification or ultrafiltration, then followed by RO and disinfection—the water that’s now used for groundwater recharge), pure RO (secondary treated wastewater that had undergone microfiltration, RO, and disinfection for low-pressure boiler feed water), and ultrapure RO (microfiltration,  RO, disinfection, and second-pass RO for high-pressure boiler feed).

Both West Basin and WRD have committed to increasing use of recycled water as a means of diversifying their water supply portfolios. To this, West Basin has added more efficient water conservation and ocean desal. The target shared by both agencies, to increase the amount of recycled water used in Los Angeles’ seawater barriers from 75% to 100%, is also a goal in Orange County. Next Page >

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February 17th, 2009 12:43 PM PT

The author notes, with respect to recycled (reclaimed) water that epidemiological studies, have identified no significant health risks in communities using reclaimed water. The rejoinder, when were these studies conducted, what did these studies include, and was the build up of antibiotic resistance through gene transfer included in such studies? If not, then we have a problem. My group has tested 6 systems in California that are producing recycled water per Title 22 criteria, all had chlorine resistant bacteria coming through. This is a potential public health risk and those interested should read the paper by Matt Wook Chang, entitled---"Toxicogenomic Response to Chlorination Includes Induction of Major Virulence Genes in Staphylococcus aureus". This paper discusses the enhancement of virulence by the use of chlorine, and in this case discusses Staph and MRSA. The interesting thing here is that the human immune system uses a chlorine system to destroy pathogens. The phagocytes after engulfing a pathogen sequesters it into a small pouch and then injects a chlorine analogue, but if the pathogen is chlorine resistant----then what? Additionally, many antibiotics are bacteriostatic, that means that these drugs merely arrest the growth of the pathogen but do not kill them, the really killing depends on the immune system. Thus if one gets an antibiotic resistant-chlorine resistant pathogen, what is the result? Did the above noted epidemiological studies consider any of these issues? Of these six plants we studied, we did extra studies on two of these plants. Those extra studies looked at antibiotic resistance; in both cases we found bacteria that were multi-antibiotic resistant, in one case resistance to 11 of the 12 antibiotics in our Kirby Bauer set. Pathogens were reviewed in a paper by Joan B Rose, under a WERF contract in 2004, (see Valerie Harwood's paper which is a reissue of the Rose study---"Validity of the Indicator Organism Paradigm for Pathogen Reduction in Reclaimed Water and Public Health Protection". These studies looked at sewer plants producing reclaimed water in Florida, Arizona and California. That study was conducted over a year and it noted pathogens in the reclaimed water. Giardia cysts were found in 84% of the final treated water. Enteric viruses were found in 31% of the final product in 2/3 of these plants and Cryptosporidum were noted in 71% of the final product of all tested plants. Thus pathogens and resistant pathogens do get through into the environment where niches can be established and these may act as lending libraries. Rose also noted that the current suite of indicators used to establish public health safety did not correlate with the actual universe of pathogens. Consequently, the water may pass standards but this may bear little relationship to actual public health risk. One plant studied by Rose was the City of Santa Barbara's El Estero. In my discussing this study with the El Estero staff, it was noted that in spite of the findings, the city had made no changes to the plant's operations. The plant I discussed above that showed bacteria with resistance to 11 of the 12 Kirby Bauer suite was also El Estero. Thus the subject of toilet to tap is an issue, but perhaps the more serious issue is the exposure of communities to recycled water used for irrigation of public access areas. Additionally, since this water is used for irrigation of leafy greens consumed raw, it would be interesting to see specific studies that considered the epidemiology of gene transfer to the flora of the human gut. All sewer plants in California producing recycled water work off the same state criteria. These criteria do not consider antibiotic resistance, transfer of genetic information nor do the lab tests consider viable but non-culturable. Accordingly, it is not unreasonable that my group is finding resistant organisms in the recycled water. Thus pathogens and resistant pathogens do get through into the environment where niches can be established and these may act as lending libraries. Amy Pruden, et al, (2006) followed genetic information (antibiotic resistant genes) through sewer plants into the open environment and thence into the drinking water supply. The genetic information is not inhibited by chlorine since it is not alive, in the sense of a living cell. Also because of its small size, this genetic material slips through most of the current filtering systems utilized by recycled water or drinking water treatment systems. What are the chances for inadvertent acquisition of resistance from environmental contamination such as through recycled water? Gerba and Rusin conducted research about the passage from finger to mouth of pathogens found on typical household objects. Others have documented surface contamination as a mechanical vector for pathogens. Thus what of the dwellings and towns down wind from sprinkler irrigation with recycled water? Drift at night, when many municipal programs use recycled water to irrigate neighborhood parks, finds drift and survival of pathogens enhanced. Considering the proximity of residences adjacent to public parks, just across the street, the distances may not be sufficient to assure public health protection. In the arid portions of the country, and during the summer when night irrigation is underway, many windows are open. In a German study, the recommended setback was 300 meters (roughly 1000 feet) between sprinklers and human settlements. This is hardly the case in most American cities. Please remember that the German government, unlike the U.S. system, is the responsible party for health care. The indicator organisms used commonly include Escherichia coli. These are the organisms that are normally killed by low-level disinfection. They are vegetative bacteria that are highly susceptible to both chemical disinfection and heat disinfection. However, in the viable but non-culturable state, the standard lab tests do not pick them up. This is a well known fact. As noted from the work by Rose, recycled water contains a large range of organisms besides E. coli. This raises the logical question of survival for the more robust organisms. The non-enveloped viruses are hard to kill. Pathogens that require high-level disinfection are missed by sewage treatment processes. These are those pathogens that contaminate semicritical medical devices such as the scopes inserted into the lower bowel. No sewer treatment plant reaches high level-disinfection. These bacteria when released are thus able to colonize environmental niches, and animals, including humans, through ingestion. Once ingested, the plasmids may be transferred to normal flora, and subsequently to pathogenic bacteria found in humans or animals, making later treatment with particular antibiotics ineffective. Also one must consider transfer of genetic information from these organisms to more robust organisms as highlighted by Sjolund et al. (2005) in the paper---"Persistence of resistant Staphylococcus epidermidis after single course of clarithromycin". That paper indicated that resistance in the normal flora, which may last up to four-years, might contribute to increased resistance in higher-grade pathogens through interspecies transfer. Sjolund et al go on to note that since populations of the normal biota are large, this affords the chance for multiple and different resistant variants to develop. This thus enhances the risk for spread to populations of pathogens. Furthermore, there is crossed resistance. For example, vancomycin resistance may be maintained by using macrolides. Again, where are the epidemiological studies on these situations? So, how fast can antibiotic resistance develop and what are the costs? Schentag, et al. (2003), followed surgical patients with the subsequent results. Pre-op nasal cultures found Staphylococcus aureus 100% antibiotic susceptible. Pre-op prophylactic antibiotics were administered. Following surgery, cephalosporin was administered. Ninety percent of the patients went home at post-op day 2 without infectious complications. Nasal bacteria counts on these patients had dropped from 10/5th to 10/3rd, but were now a mix of sensitive, borderline, and resistant Staphylococcus sp. By comparison, prior to surgery, all of the patients' Staphylococcus samples had been susceptible to antibiotics. For the patients remaining in the hospital and who were switched on post-op day 5 to a second generation cephalosporin (ceftazidine), showed bacterial counts up 1000-fold when assayed on post-op day 7 and most of these were methicillin resistant Staphylococcus aureus (MRSA). These patients were switched to a 2-week course of vancomycin. Cultures from those remaining in the hospital on day 21, revealed vancomycin resistant enterococcus (VRE) and candida. Vancomycin resistant enterococci infections can produce mortality rates of between 42 and 81%. Note in the above, that these patients harbored NO resistant bacteria in their nasal cavities upon entry to the hospital. But what would be the result if there had been inadvertent acquisition of resistance from environmental contamination such as through recycled water? Where are the epidemiological studies on recycled water under these conditions? I think it boils down to this absence of evidence is not evidence of absence. This then brings into question the current paradigm on infection and its dose response to a certain load of a particular pathogen, i.e., ID and LD 50s. Lateral transfer of mobile genetic elements conferring resistance is not considered in this old paradigm, often used in epidemiological studies. With the prodigious capacity for the gut bacteria to multiply, once the lateral transfer has taken place, very small original numbers---well below the old paradigms can be multiplied into impressive numbers. Since viruses and phages are also involved, their capacity to multiply, which dwarfs that of bacteria, must also be included. Thus there is a need for a new paradigm; unfortunately, the regulatory community seems not to recognize this. When one considers the multiplication within sewer plants and also within their byproducts, disbursement into the environment, the transfer to background organisms, hence to man and his animals, then the remultiplication within commensals, the emerging picture is worrisome. The current standards controlling sewer plant operations, and thus recycled water consider none of these issues. This comment therefore contends that this unconsidered avenue for the spread of antibiotic resistance and amplification of risk for a pandemic needs greater awareness within the water reuse community and the public. Without the perspective of a broader analysis of this issue, future policy may be no more that the post hoc rationalization for a series of missed opportunities. It would seem reckless to proceed without a broader picture. Unfortunately, the principal regulatory bodies dealing with recycled water seem to be essentially oblivious to these concepts. +++++++++++++++++++++++++++ REFERENCES Rooklidge SJ. Environmental antimicrobal contamination from terraaccumulation and difuse pollution pathways. Sci Toatl Environ 2004 Jun 5;325(1-3):1-13. Golet EM et al. Determination of fluoroquinolone antimicrobial agents in sewage sludge and sludge treated soils using accelerated solvent extraction followed by solid phase extraction. Anal Chem. 2002 Nov 1;74(21):5455-62.Overall recovery ranged from 82 to 94% from sludge and 75 to 92% for soils. Golet EM, et al. Environmental exposure assessment of fluoroquinolone antibacterial agents from sewage to soil. Environ Sci Technol. 2003 Aug 1;37(15):3243-9. These results suggest sewage sludge as the main reservoir of FQ residues. Ray JL, Nielsen KM. Experimental methods for assaying natural transformation and inferring horizontal gene transfer. Methods Enzymol. 2005;395:491-520. Occurrence and reservoirs of antibiotic resistance genes in the environment. Seveno, Nadine A. et al. Reviews in Medical Microbiology. Jan 2002, 13(1): 15-27. Hassen A., et al. Microbial characterization during composting of municipal solid waste. Bioresour Technol 2001 Dec;80(3):217-25. Ray JL, et al. Experimental methods for assaying natural transformation and inferring horizontal gene transfer. Methods Enzymol. 2005;395:491-520. Fontaine, T. D., III, and A. W. Hoadley. 1976. Transferrable drug resistance associated with coliforms isolated from hospital and domestic sewage. Health Lab. Sci. 4:238-245. Grabow, W. O. K., and O. W. Prozesky. 1973. Drug resistance of coliform bacteria in hospital and city sewage. Antimicrob. Agents Chemother. 3:175-180. Linton, K. B., M. H. Richmond, R. Bevan, and W. A. Gillespie. 1974. Antibiotic resistance and R factors in coliform bacilli isolated from hospital and domestic sewage. J. Med. Microbiol. 7:91-103. Walter, M. V., and J. W. Vennes. 1985. Occurrence of multiple-antibiotic-resistant enteric bacteria in domestic sewage and oxidation lagoons. Appl. Environ. Microbiol. 50:930-933. Rhodes G, Huys G, Swings J, McGann P, Hiney M, Smith P, Pickup RW. Distribution of oxytetracycline resistance plasmids between aeromonads in hospital and aquaculture environments: implication of Tn1721 in dissemination of the tetracycline resistance determinant tet A. Appl Environ Microbiol 2000 Sep;66(9):3883-90. Seveno NA. Occurrence and reservoirs of antibiotic resistance genes in the environment. Reviews in Medical Microbiology. 13(1):15-27, January 2002. Cooley MB. Colonization of Arabidopsis thaliana with Salmonella enterica and Enterohemorrhagic Escherichia coli O157:H7 and Competition by Enterobacter asburiae. Applied and Environmental Microbiology, August 2003, p. 4915-4926, Vol. 69, No. 8. Marcinek H, Wirth R, Muscholl-Silberhorn A, Gauer M. Enterococcus faecalis gene transfer under natural conditions in municipal sewage water treatment plants. Appl Environ Microbiol 1998 Feb;64(2):626-32. Iversen A, Kuhn I, Franklin A, Mollby R. High prevalence of vancomycin-resistant enterococci in Swedish sewage. Appl Environ Microbiol 2002 Jun;68(6):2838-42. Reinthaler FF, Posch J, Feierl G, Wust G, Haas D, Ruckenbauer G, Mascher F, Marth E. Antibiotic resistance of E. coli in sewage and sludge. Water Res 2003 Apr;37(8):1685-90. Cenci G, Morozzi G, Daniele R, Scazzocchio F. Antibiotic and metal resistance in "Escherichia coli" strains isolated from the environment and from patients. Ann Sclavo 1980 Mar-Apr;22(2):212-26. Heberer T, Reddersen K, Mechlinski A. From municipal sewage to drinking water: fate and removal of pharmaceutical residues in the aquatic environment in urban areas. . Water Sci Technol 2002;46(3):81-8. Rusin P, et al. Comparative surface-to-hand and fingertip-to-mouth transfer efficiency of gram-positive bacteria, gram-negative bacteria, and phage. J Appl Microbiol. 2002;93(4):585-92; See also: Shivi Selvaratnam and J. David Kunberger. Increased frequency of drug-resistant bacteria and fecal coliforms in an Indiana Creek adjacent to farmland amended with treated sludge. Can. J. Microbiol./Rev. can. microbiol. 50(8): 653-656 (2004). This paper discusses wash-off into waterways. Gerba CP et al. Effect of sediments on the survival of Ericherichia coli in marine waters. AEM July 1976 114-20. LaBelle RL, et al. Influence of pH, salinity and organic matter on the absorption of enterovirus to estuarine sediments. AEM July 1979 93-101---sediment can act as a reservoir for enterovirus. Sjolund et al. (2005) Emerging Infectious Diseases (Vol. 11, # 9, Sept 2005 @ p. 1389 et seq), Schentag, et al , as founs in Walsch, C. Antibiotics----, Actions, Origins, Resistance, (March 2003) New York: ASM Press.

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