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Background: Western Lake Erie is suffering from harmful cyanobacterial blooms, primarily toxic Microcystis spp., affecting the ecosystem, water safety, and the regional economy. Continued bloom occurrence has raised concerns about public health implications. However, there has been no investigation regarding the potential increase of Legionella and antibiotic resistance genes in source water, and disinfection byproducts in municipal treated drinking water caused by these bloom events., Methods: Over 2 years, source water (total n  = 118) and finished water (total n  = 118) samples were collected from drinking water plants situated in western Lake Erie (bloom site) and central Lake Erie (control site). Bloom-related parameters were determined, such as microcystin (MC), toxic Microcystis , total organic carbon, N, and P. Disinfection byproducts (DBPs) [total trihalomethanes (THMs) and haloacetic acids (HAAs)] were assessed in finished water. Genetic markers for Legionella , antibiotic resistance genes, and mobile genetic elements were quantified in source and finished waters., Results: Significantly higher levels of MC-producing Microcystis were observed in the western Lake Erie site compared to the control site. Analysis of DBPs revealed significantly elevated THMs concentrations at the bloom site, while HAAs concentrations remained similar between the two sites. Legionella spp. levels were significantly higher in the bloom site, showing a significant relationship with total cyanobacteria. Abundance of ARGs ( tet Q and sul 1) and mobile genetic elements (MGEs) were also significantly higher at the bloom site., Discussion: Although overall abundance decreased in finished water, relative abundance of ARGs and MGE among total bacteria increased after treatment, particularly at the bloom site. The findings underscore the need for ongoing efforts to mitigate bloom frequency and intensity in the lake. Moreover, optimizing water treatment processes during bloom episodes is crucial to maintain water quality. The associations observed between bloom conditions, ARGs, and Legionella , necessitate future investigations into the potential enhancement of antibiotic-resistant bacteria and Legionella spp. due to blooms, both in lake environments and drinking water distribution systems., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Lee, Lee, Hu and Marion.)

The global concern over antimicrobial resistance (AMR) and its impact on human health is evident, with approximately 4.95 million annual deaths attributed to antibiotic resistance. Regions with inadequate water, sanitation, and hygiene face challenges in responding to AMR threats. Enteric bacteria, particularly E. coli , are common agents linked to AMR-related deaths (23% of cases). Culture-based methods for detecting tetracycline-resistant E. coli may be of practical value for AMR monitoring in limited resource environments. This study evaluated the ColiGlow™ method with tetracycline for classifying tetracycline-resistant E. coli . A total of 61 surface water samples from Kentucky, USA (2020-2022), provided 61 presumed E. coli isolates, of which 28 isolates were obtained from tetracycline-treated media. Species identification and tetracycline resistance evaluation were performed. It was found that 82% of isolates were E. coli , and 18% were other species; 97% were identified as E. coli when using the API20E identification system. The MicroScan system yielded Enterobacter cloacae false positives in 20% of isolates. Adding tetracycline to ColiGlow increased the odds of isolating tetracycline-resistant E. coli 18-fold. Tetracycline-treated samples yielded 100% tetracycline-resistant E. coli when the total E. coli densities were within the enumeration range of the method. ColiGlow with tetracycline shows promise for monitoring tetracycline-resistant E. coli in natural waters and potentially aiding AMR surveillance in resource-limited settings among other environments.

Introduction: Quantitative studies on drinking water perceptions in Appalachia are limited. High-profile water infrastructure failures in the U.S. and Eastern Kentucky, coupled with human-made and natural disasters in the Appalachian Region, have likely impacted opinions regarding tap water., Purpose: To use existing unexplored data to describe baseline tap water v. bottled water consumption in Kentucky., Methods: Telephone-based cross-sectional data were obtained from the 2013 Kentucky Health Issues Poll (KHIP) directed by the Foundation for a Healthy Kentucky. Among many items in KHIP, self-reported consumption of bottled water over tap water, reasons for bottled water use, and demographic data were obtained., Results: Among Appalachian (n=356) and non-Appalachian (n=1,125) Kentucky respondents, a significantly higher frequency of Appalachian Kentuckians reported drinking bottled water more often than tap water relative to non-Appalachian Kentuckians (57% v. 34%; X 2 p < 0.001). Appalachian residency significantly predicted bottled water consumption in simple and multivariable logistic regression adjusted for significant covariates (i.e., age, sex, and race). Among persons consuming bottled water more than tap water, Appalachian Kentuckians reported significantly more concerns regarding tap water taste or smell ( p = 0.005) and safety ( p = 0.008) than non-Appalachians., Implications: These results from 2013 data pre-date headline news items related to public water and likely underestimate current bottled water preferences. New data are needed, and these results warrant further investigation into tap water aesthetics in Appalachia, bottled water consumption impacts on personal finances, and approaches to build public trust for public drinking water among multiple populations including Appalachian Kentuckians., Competing Interests: Cover Page Footnote No competing financial or editorial interests were reported by the author of this paper. The study was made possible through the publicly accessible data and data collection efforts of the Foundation for a Healthy Kentucky and Interact for Health. The research question and knowledge of the data source was made possible through citizen and policy maker engagement with the author at a Shaping Our Appalachian Region (SOAR) summit., (Copyright © 2023 Jason W. Marion.)

Objective: Research exists examining sunburn risks, sun protective behaviors, and interventions among pool lifeguards; however, ocean lifeguard research is limited. This study aimed to determine sunburn prevalence and associations between sunburn with photoprotective attitudes and habits among Florida ocean lifeguards., Methods: A cross-sectional study was electronically administered in 2021 to ocean lifeguards using sun protection questions. Recruitment occurred through three lifeguard agencies. The frequency of self-reported sunburns from the prior season and the opinions and practices related to photoprotection and tanning were obtained., Results: Complete data were obtained from 77 (37%) of 207 lifeguards who served during the 2020 swimming season (mean [SD] age, 22.9 [8.31] years; 40 male (52.0%) and 37 female (48.0%)). Sunburn was common with only four (5.2%) lifeguards reporting no sunburn. In total, 26 (33.8%) reported five or more sunburns. The median sunburn frequency was three. Reporting three or more sunburns was positively associated with being a teenager (16 to 18 years) (aOR: 14.9, 95% CI 3.5 to 64.2) or young adult (19 to 23 years) (aOR: 6.4, 95% CI 1.6 to 25.2) and having a neutral opinion regarding sunscreen effectiveness (aOR: 4.5, 95% CI 1.1 to 18.7) in logistic regression models., Limitations: Self-reported sunburns were recalled and not clinically evaluated. Recall, participation, and social desirability biases may have been present., Conclusion: Ocean lifeguards reported appreciably high rates of sunburn, especially younger lifeguards. Increased photoprotection education, engineering controls, and research are warranted for this occupational group., Competing Interests: DISCLOSURES: Dr. Brown reported receiving support from the Central Appalachian Regional Education and Research Center from CDC/NIOSH as Director of the Industrial Hygiene Core. Mr. Hayworth and Dr. Marion report no conflicts of interest relevant to the content of this article., (Copyright © 2023. Matrix Medical Communications. All rights reserved.)

The behaviors and opinions regarding e-cigarette use and campus policies prohibiting vaping vary greatly among college students nationally. Kentucky is one of the four U.S. states with the highest tobacco use prevalence, and characterizing e-cigarette use, trends and policy opinions among Kentucky undergraduates may inform interventions. To characterize population-level differences in e-cigarette-related behaviors and policy opinions among undergraduates from 2014 to 2018, results from two cross-sectional surveys (2014 and 2018) from a public regional university in south-central Kentucky were analyzed. Students from randomly selected undergraduate general studies courses completed a 5-minute in-class survey. Data were obtained from 514 and 519 respondents in 2014 and 2018, respectively. Mean age did not differ (19.9 and 20.1 years; p = 0.41) nor did class rank (p = 0.30) by survey year. Chi-square analysis indicated previous 30-day e-cigarette use was higher in 2018 than 2014 (28% vs. 18%; p < 0.001), and current cigarette use was lower in 2018 than 2014 (13% vs. 25%; p < 0.001). When current smoking and recent e-cigarette use were combined as a use variable, there was no significant difference between 2018 (29%) and 2014 (30%). Fraternity/sorority affiliation, being under 22 years old, male gender, out-of-state residency, and having a smoking parent were associated with recent e-cigarette use in multivariable logit models. Support for the on-campus vaping prohibition was lower among 2018 respondents (68% approval) compared to 2014 respondents (74% approval), respectively (p = 0.022). Overall, these findings may inform policy, population-specific health communications, and future research., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 Eastern Kentucky University.)

Milk vending machines (MVMs) are growing in popularity in Kenya and worldwide. Milk vending machines dispense varying quantities of locally sourced, pasteurized milk. The Kenya Dairy Board has a regulatory framework, but surveillance is weak because of several factors. Milk vending machines' milk is not routinely screened for antibiotics, thereby increasing potential for antibiotic misuse. To investigate, a total of 80 milk samples from four commercial providers ( N = 25), street vendors ( N = 21), and three MVMs ( N = 34) were collected and screened in Eldoret, Kenya. Antibiotic residue surveillance occurred during December 2016 and January 2017 using Idexx SNAP ® tests for tetracyclines, sulfamethazine, beta-lactams, and gentamicin. Overall, 24% of MVM samples and 24% of street vendor samples were presumably positive for at least one antibiotic. No commercial samples were positive. Research into cost-effective screening methods and increased monitoring by food safety agencies are needed to uphold hazard analysis and critical control point for improving antibiotic stewardship throughout the Kenyan private dairy industry.

Background: Increases in outdoor temperature may lead to increases in sunburn, outdoor exposure, and skin cancer in human populations., Objective: This study aimed to quantify sunburn incidence and risk for Ohio beachgoers exposed to varying outdoor conditions., Methods: Sunburn incidence data were obtained through a prospective cohort study at East Fork Lake (Cincinnati, Ohio, USA). Recruitment occurred over 26 weekend days. Beach interviews and follow-up telephone interviews obtained exposure and health information. New sunburns were self-reported 8-9 days post-enrollment. Survey data were paired with ultraviolet radiation (UVR) index and temperature data for statistical analysis., Results: Among 947 beachgoers, new sunburns were reported in 18% of swimmers. Sunburn incidence was associated with temperature (odds ratio = 1.2; 95% CI: 1.1 - 1.4) and UVR index (odds ratio = 1.6; 95% CI: 1.0 - 2.5) in models adjusted for water exposure, arrival time, and beach visit frequency. Some evidence of a temperature+UVR interaction was observed., Limitations: Exposure and sunburn data were self-reported without clinical diagnosis and date of onset. The follow-up period enabled sunburns to be reported from a variety of days rather than only the beach visit day thereby limiting interpretation. Sun protection behaviors were not evaluated., Conclusions: Temperature and UVR influence sunburn frequency. Temperature, however was more strongly associated with sunburn in beachgoers than the nearest measured UVR index, suggesting future investigations are needed to better understand how temperature effects sunburn development. Interventions for decreasing sunburn are needed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Lake Erie beaches exhibit impaired water quality due to fecal contamination and cyanobacterial blooms, though few studies address potential relationships between these two public health hazards. Using quantitative polymerase chain reaction (qPCR), Microcystis aeruginosa was monitored in conjunction with a human-associated fecal marker (Bacteroides fragilis group; g-Bfra), microcystin, and water quality parameters at two beaches to evaluate their potential associations. During the summer of 2010, water samples were collected 32 times from both Euclid and Villa Angela beaches. The phycocyanin intergenic spacer (PC-IGS) and the microcystin-producing (mcyA) gene in M. aeruginosa were quantified with qPCR. PC-IGS and mcyA were detected in 50.0% and 39.1% of samples, respectively, and showed increased occurrences after mid-August. Correlation and regression analyses showed that water temperature was negatively correlated with M. aeruginosa markers and microcystin. The densities of mcyA and the g-Bfra were predicted by nitrate, implicating fecal contamination as contributing to the growth of M. aeruginosa by nitrate loading. Microcystin was correlated with mcyA (r = 0.413, p < 0.01), suggesting toxin-producing M. aeruginosa populations may significantly contribute to microcystin production. Additionally, microcystin was correlated with total phosphorus (r = 0.628, p < 0.001), which was higher at Euclid (p < 0.05), possibly contributing to higher microcystin concentrations at Euclid.

Background & Objective: Recreational waters impacted by fecal contamination have been linked to gastrointestinal illness in swimmer populations. To date, few epidemiologic studies examine the risk for swimming-related illnesses based upon simultaneous exposure to more than one microbial surrogate (e.g. culturable E. coli densities, genetic markers). We addressed this research gap by investigating the association between swimming-related illness frequency and water quality determined from multiple bacterial and viral genetic markers., Methods: Viral and bacterial genetic marker densities were determined from beach water samples collected over 23 weekend days and were quantified using quantitative polymerase chain reaction (qPCR). These genetic marker data were paired with previously determined human exposure data gathered as part of a cohort study carried out among beach users at East Fork Lake in Ohio, USA in 2009. Using previously unavailable genetic marker data in logistic regression models, single- and multi-marker/multi-water quality indicator approaches for predicting swimming-related illness were evaluated for associations with swimming-associated gastrointestinal illness., Results: Data pertaining to genetic marker exposure and 8- or 9-day health outcomes were available for a total of 600 healthy susceptible swimmers, and with this population we observed a significant positive association between human adenovirus (HAdV) exposure and diarrhea (odds ratio  = 1.6; 95% confidence interval: 1.1-2.3) as well as gastrointestinal illness (OR  = 1.5; 95% CI: 1.0-2.2) upon adjusting for culturable E. coli densities in multivariable models. No significant associations between bacterial genetic markers and swimming-associated illness were observed., Conclusions: This study provides evidence that a combined measure of recreational water quality that simultaneously considers both bacterial and viral densities, particularly HAdV, may improve prediction of disease risk than a measure of a single agent in a beach environment likely influenced by nonpoint source human fecal contamination.

Gulls represent one of the major fecal contamination sources responsible for the degradation of water quality at Lake Erie beaches. For assessing gull-associated fecal contamination, a real-time quantitative PCR assay (qPCR) targeting 16S rRNA gene sequences from Catellicoccus marimammalium, which are abundant in gull feces, was developed and evaluated by comparing assay results with beach survey data that included gull counting, and quantifying densities of Escherichia coli and human-associated fecal markers at two Lake Erie beaches. In evaluating the specificity and sensitivity of the qPCR assay with animal and wastewater samples, C. marimammalium was detected in most gull fecal samples (80.7%), some chicken fecal samples (24.1%), but was not readily detected from other fecal samples of animals and humans, and wastewater. Among 66 Lake Erie water samples collected in 2010, C. marimammalium was frequently detected from Villa Angela (36.4%) and Headlands beaches (57.6%). C. marimammalium densities were not associated with E. coli densities or sanitary survey data. E. coli counts were likely driven by other sources, such as human, rather than gulls at the study sites. The presumption that human contamination influenced E. coli counts was supported by more frequent detection of the human-specific Bacteroides gyrB marker (gyrB) at Villa Angela (33.3%) than Headlands (6.1%). Since E. coli may not be an effective indicator for assessing gull-related fecal contamination at these beaches, where contamination sources are mixed, our novel qPCR assay can be useful for understanding fecal source contributions from gulls not explained by gull abundance or E. coli densities., (Copyright © 2013 Elsevier B.V. All rights reserved.)

The genus Arcobacter has been associated with human illness and fecal contamination by humans and animals. To better characterize the health risk posed by this emerging waterborne pathogen, we investigated the occurrence of Arcobacter spp. in Lake Erie beach waters. During the summer of 2010, water samples were collected 35 times from the Euclid, Villa Angela, and Headlands (East and West) beaches, located along Ohio's Lake Erie coast. After sample concentration, Arcobacter was quantified by real-time PCR targeting the Arcobacter 23S rRNA gene. Other fecal genetic markers (Bacteroides 16S rRNA gene [HuBac], Escherichia coli uidA gene, Enterococcus 23S rRNA gene, and tetracycline resistance genes) were also assessed. Arcobacter was detected frequently at all beaches, and both the occurrence and densities of Arcobacter spp. were higher at the Euclid and Villa Angela beaches (with higher levels of fecal contamination) than at the East and West Headlands beaches. The Arcobacter density in Lake Erie beach water was significantly correlated with the human-specific fecal marker HuBac according to Spearman's correlation analysis (r = 0.592; P < 0.001). Phylogenetic analysis demonstrated that most of the identified Arcobacter sequences were closely related to Arcobacter cryaerophilus, which is known to cause gastrointestinal diseases in humans. Since human-pathogenic Arcobacter spp. are linked to human-associated fecal sources, it is important to identify and manage the human-associated contamination sources for the prevention of Arcobacter-associated public health risks at Lake Erie beaches.

Current approaches for assessing human health risks associated with cyanotoxins often rely on the quantification of microcystin. Significant limitations of current approaches are cost and time to obtain a result. To address these challenges, a numerical index for screening microcystin risks above the World Health Organization's (WHO) low-risk threshold for microcystin was developed for eutrophic Midwestern U.S. lakes based on water quality results from 182 beach water samples collected from seven Ohio lakes. In 48 (26.4%) samples we observed microcystin concentrations as measured by ELISA that exceeded the 4 μg/L microcystin threshold. A multivariable logistic regression model using practical real-time measures of in vivo phycocyanin (by fluorometry) and secchi depth was constructed to estimate the probability of a beach sample exceeding 4 μg/L microcystin. The final model achieved statistical significance (p = 0.030) as well as good calibration (as measured by the goodness-of-fit test comparing observed to expected counts within deciles of risk based on the model, p = 0.329) and discrimination (as indicated by the area under the receiver-operator-curve (0.795)). These results demonstrate two rapid and practical measures of recreational water quality are effective in identifying "at risk" lake conditions warranting additional management (e.g., advisory and/or advanced testing).

Bacteroides spp. has gained substantial interest among the suggested potential candidates for alternative faecal indicators for untreated recreational waters by the US EPA. Interest in Bacteroides as a faecal indicator is based upon the relative abundance of selected members of the Bacteroides genus in the human colon and human faeces. In this study, we developed a real-time PCR detection system based on gyrase B subunit genes (gyrB) specific to Bacteroides fragilis. The gryB-based method was compared with previously described 16S rRNA-based real-time qPCR methods and evaluated for specificity, sensitivity and robustness in detecting B. fragilis from untreated recreational water impacted by human and non-human faecal sources. The new gyrB-based system only detected B. fragilis, whereas the 16S rRNA-based methods generated cross-amplifications with other Bacteroides and Prevotella species. We used a procedure of prefiltration, filtration, sonication and DNA concentration in order to improve the DNA extraction efficiency and the sensitivity of the real-time PCR while removing interference. The amplification and sequencing of PCR products generated by the gyrB-based method confirmed that gyrB-amplified sequences only contained B. fragilis. This rapid method is useful for quantifying faecal contamination and may assist beach and watershed managers in elucidating possible contamination sources.

Recent epidemiology studies examining U.S. recreational water exposure and illness relationships have focused primarily on coastal and Great Lakes beaches. Human-made lakes in the U.S. have received little attention in epidemiology studies despite contributing to more waterborne disease epidemics annually than coastal U.S. waters. In a comprehensive beach cohort study, we examined relationships between water quality indicators and reported adverse health outcomes among users of a beach at an inland U.S. lake. Human health data was collected over 26 swimming days during the 2009 swimming season in conjunction with water quality measurements. Adverse health outcomes were reported 8-9 days post-exposure via a phone survey. Wading, playing or swimming in the water was observed to be a significant risk factor for GI illness (adjusted odds ratio (AOR) of 3.2; CI 1.1, 9.0). Among water users, Escherichia coli density was significantly associated with elevated GI illness risk where the highest E. coli quartile was associated with an AOR of 7.0 (CI 1.5, 32). GI illness associations are consistent with previous freshwater epidemiology studies. Our findings are unique in that our observations of positive associations with GI illness risk are based upon a single daily E. coli measurement. Lastly, this study focused on an understudied issue, illness risk at inland reservoirs. Our results support the usefulness of E. coli as a health-relevant indicator of water quality for this inland U.S. beach., (Copyright © 2010 Elsevier Ltd. All rights reserved.)