Cryptosporidiosis Susceptibility and Risk: A Case Study

Regional estimates of cryptosporidiosis risks from drinking water exposure were developed and validated, accounting for AIDS status and age. We constructed a model with probability distributions and point estimates representing Cryptosporidium in tap water, tap water consumed per day (exposure characterization); dose response, illness given infection, prolonged illness given illness; and three conditional probabilities describing the likelihood of case detection by active surveillance (health effects characterization). The model predictions were combined with population data to derive expected case numbers and incidence rates per 100,000 population, by age and AIDS status, borough specific and for New York City overall in 2000 (risk characterization). They were compared with same-year surveillance data to evaluate predictive ability, assumed to represent true incidence of waterborne cryptosporidiosis. The predicted mean risks, similar to previously published estimates for this region, overpredicted observed incidence-most extensively when accounting for AIDS status. The results suggest that overprediction may be due to conservative parameters applied to both non-AIDS and AIDS populations, and that biological differences for children need to be incorporated. Interpretations are limited by the unknown accuracy of available surveillance data, in addition to variability and uncertainty of model predictions. The model appears sensitive to geographical differences in AIDS prevalence. The use of surveillance data for validation and model parameters pertinent to susceptibility are discussed.     

A Quantitative Risk Assessment of Waterborne Cryptosporidiosis in France Using Second-Order Monte Carlo Simulation

A pragmatic quantitative risk assessment (QRA) of the risks of waterborne Cryptosporidium parvum infection and cryptosporidiosis in immunocompetent and immunodeficient French populations is proposed. The model takes into account French specificities such as the French technique for oocyst enumeration performance and tap water consumption. The proportion of infective oocysts is based on literature review and expert knowledge. The probability of infection for a given number of ingested viable oocysts is modeled using the exponential dose-response model applied on published data from experimental infections in immunocompetent human volunteers challenged with the IOWA strain. Second-order Monte Carlo simulations are used to characterize the uncertainty and variability of the risk estimates. Daily risk of infection and illness for the immunocompetent and the immunodeficient populations are estimated according to the number of oocysts observed in a single storage reservoir water sample. As an example, the mean daily risk of infection in the immunocompetent population is estimated to be 1.08 x 10(-4) (95% confidence interval: [0.20 x 10(-4); 6.83 x 10(-4)]) when five oocysts are observed in a 100 L storage reservoir water sample. Annual risks of infection and disease are estimated from a set of oocyst enumeration results from distributed water samples, assuming a negative binomial distribution of day-to-day contamination variation. The model and various assumptions used in the model are fully explained and discussed. While caveats of this model are well recognized, this pragmatic QRA could represent a useful tool for the French Food Safety Agency (AFSSA) to define recommendations in case of water resource contamination by C. parvum whose infectivity is comparable to the IOWA strain.     

An Integrated Model of Infection Risk in a Health-Care Environment

Certain respiratory tract infections can be transmitted by hand-to-mucous-membrane contact, inhalation, and/or direct respiratory droplet spray. In a room occupied by a patient with such a transmissible infection, pathogens present on textile and nontextile surfaces, and pathogens present in the air, provide sources of exposure for an attending health-care worker (HCW); in addition, close contact with the patient when the latter coughs allows for droplet spray exposure. We present an integrated model of pertinent source-environment-receptor pathways, and represent physical elements in these pathways as "states" in a discrete-time Markov chain model. We estimate the rates of transfer at various steps in the pathways, and their relationship to the probability that a pathogen in one state has moved to another state by the end of a specified time interval. Given initial pathogen loads on textile and nontextile surfaces and in room air, we use the model to estimate the expected pathogen dose to a HCW's mucous membranes and respiratory tract. In turn, using a nonthreshold infectious dose model, we relate the expected dose to infection risk. The system is illustrated with a hypothetical but plausible scenario involving a viral pathogen emitted via coughing. We also use the model to show that a biocidal finish on textile surfaces has the potential to substantially reduce infection risk via the hand-to-mucous-membrane exposure pathway.     

Considering the Risk of Infection by Cryptosporidium via Consumption of Municipally Treated Drinking Water from a Surface Water Source in a Southwestern Ontario Community

Through the use of case‐control analyses and quantitative microbial risk assessment (QMRA), relative risks of transmission of cryptosporidiosis have been evaluated (recreational water exposure vs. drinking water consumption) for a Canadian community with higher than national rates of cryptosporidiosis. A QMRA was developed to assess the risk of Cryptosporidium infection through the consumption of municipally treated drinking water. Simulations were based on site‐specific surface water contamination levels and drinking water treatment log₁₀ reduction capacity for Cryptosporidium. Results suggested that the risk of Cryptosporidium infection via drinking water in the study community, assuming routine operation of the water treatment plant, was negligible (6 infections per 10¹³ persons per day—5th percentile: 2 infections per 10¹⁵ persons per day; 95th percentile: 3 infections per 10¹² persons per day). The risk is essentially nonexistent during optimized, routine treatment operations. The study community achieves between 7 and 9 log₁₀Cryptosporidium oocyst reduction through routine water treatment processes. Although these results do not preclude the need for constant vigilance by both water treatment and public health professionals in this community, they suggest that the cause of higher rates of cryptosporidiosis are more likely due to recreational water contact, or perhaps direct animal contact. QMRA can be successfully applied at the community level to identify data gaps, rank relative public health risks, and forecast future risk scenarios. It is most useful when performed in a collaborative way with local stakeholders, from beginning to end of the risk analysis paradigm.     

Quantitative Microbial Risk Assessment of Cryptosporidiosis and Giardiasis from Very Small Private Water Supplies

This article reports a quantitative microbial risk assessment of the risk of Giardia and Cryptosporidium in very small private water supplies. Both pathogens have been implicated in causing outbreaks of waterborne disease associated with such supplies, though the risk of endemic disease is not known. For exposure assessments, we used existing data to derive regression equations describing the relationships between the concentration of these pathogens and Escherichia coli in private water supplies. Pathogen concentrations were then estimated using national surveillance data of E. coli in private water supplies in England and France. The estimated risk of infection was very high with the median annual risk being of the order of 25–28% for Cryptosporidium and 0.4% to 0.7% for Giardia, though, in the poorer quality supplies the risk could be much higher. These risks are substantially greater than for public water supplies and well above the risk considered tolerable. The observation that observed infection rates are generally much lower may indicate increased immunity in people regularly consuming water from private supplies. However, this increased immunity is presumed to derive from increased disease risk in young children, the group most at risk from severe disease.     

Risk Assessment Can Be a Game‐Changing Information Technology—But Too Often It Isn't

The printing press was a game‐changing information technology. Risk assessment could be also. At present, risk assessments are commonly used as one‐time decision aids: they provide justification for a particular decision, and afterwards usually sit on a shelf. However, when viewed as information technologies, their potential uses are much broader. Risk assessments: (1) are repositories of structured information and a medium for communication; (2) embody evaluative structures for setting priorities; (3) can preserve information over time and permit asynchronous communication, thus encouraging learning and adaptation; and (4) explicitly address uncertain futures. Moreover, because of their “what‐if” capabilities, risk assessments can serve as a platform for constructive discussion among parties that hold different values. The evolution of risk assessment in the nuclear industry shows how such attributes have been used to lower core‐melt risks substantially through improved templates for maintenance and more effective coordination with regulators (although risk assessment has been less commonly used in improving emergency‐response capabilities). The end result of this evolution in the nuclear industry has been the development of “living” risk assessments that are updated more or less in real time to answer even routine operational questions. Similar but untapped opportunities abound for the use of living risk assessments to reduce risks in small operational decisions as well as large policy decisions in other areas of hazard management. They can also help improve understanding of and communication about risks, and future risk assessment and management. Realization of these opportunities will require significant changes in incentives and active promotion by the risk analytic community.     

Regional Risk Assessment for Point Source Pollution Based on a Water Quality Model of the Taipu River,China

Point source pollution is one of the main threats to regional environmental health. Based on a water quality model, a methodology to assess the regional risk of point source pollution is proposed. The assessment procedure includes five parts: (1) identifying risk source units and estimating source emissions using Monte Carlo algorithms; (2) observing hydrological and water quality data of the assessed area, and evaluating the selected water quality model; (3) screening out the assessment endpoints and analyzing receptor vulnerability with the Choquet fuzzy integral algorithm; (4) using the water quality model introduced in the second step to predict pollutant concentrations for various source emission scenarios and analyzing hazards of risk sources; and finally, (5) using the source hazard values and receptor vulnerability scores to estimate overall regional risk. The proposed method, based on the Water Quality Analysis Simulation Program (WASP), was applied in the region of the Taipu River, which is in the Taihu Basin, China. Results of source hazard and receptor vulnerability analysis allowed us to describe aquatic ecological, human health, and socioeconomic risks individually, and also integrated risks in the Taipu region, from a series of risk curves. Risk contributions of sources to receptors were ranked, and the spatial distribution of risk levels was presented. By changing the input conditions, we were able to estimate risks for a range of scenarios. Thus, the proposed procedure may also be used by decisionmakers for long‐term dynamic risk prediction.     

An Integrated Physical Dispersion and Behavioral Response Model for Risk Assessment of Radiological Dispersion Device (RDD) Events

A radiological dispersion device (RDD) or "dirty" bomb is a conventional explosive wrapped in radiological material. Terrorists may use an RDD to disperse radioactive material across a populated area, causing casualties and/or economic damage. Nearly all risk assessment models for RDDs make unrealistic assumptions about public behavior in their health assessments, including assumptions that the public would stand outside in a single location indefinitely. In this article, we describe an approach for assessing the risks of RDD events incorporating both physical dispersion and behavioral response variables. The general approach is tested using the City of Pittsburgh, Pennsylvania as a case study. Atmospheric models simulate an RDD attack and its likely fallout, while radiation exposure models assess fatal cancer risk. We model different geographical distributions of the population based on time of day. We evaluate aggregate health impacts for different public responses (i.e., sheltering-in-place, evacuating). We find that current RDD models in use can be improved with the integration of behavioral components. Using the results from the model, we show how risk varies across several behavioral and physical variables. We show that the best policy to recommend to the public depends on many different variables, such as the amount of trauma at ground zero, the capability of emergency responders to get trauma victims to local hospitals quickly and efficiently, how quickly evacuations can take place in the city, and the amount of shielding available for shelterers. Using a parametric analysis, we develop behaviorally realistic risk assessments, we identify variables that can affect an optimal risk reduction policy, and we find that decision making can be improved by evaluating the tradeoff between trauma and cancer fatalities for various RDD scenarios before they occur.     

The NAS Risk Paradigm as a Medium for Communication

Many journalists, public interest groups and other recipients of risk assessment information are familiar with the National Academy of Sciences risk assessment paradigm. From time to time, paradigm concepts appear in news features or community group discussions on environmental issues. With knowledge of the paradigm common to scientists, journalists, and other interested parties, the paradigm is a potentially important medium for communication between risk scientists, journalists, and the public. Specifically, the paradigm offers widely-accepted organizing principles for presenting risk information, a common language for addressing a variety of issues and concepts, and a flexible analytical system that accommodates the diversity of scientific information and policy perspectives that characterize the risk assessment process. In addition, the paradigm outlines important relationships and distinctions between risk assessment and risk management. Informed and creative use of these features of the paradigm can guide and simplify interviews between journalists or community groups and their expert sources, clarify presentation of risk information, and promote collaboration between risk scientists, journalists, and others to assure complete, objective and fair comment on risk issues of interest to the public.     

An Agent‐Based Model of Evolving Community Flood Risk

Although individual behavior plays a major role in community flood risk, traditional flood risk models generally do not capture information on how community policies and individual decisions impact the evolution of flood risk over time. The purpose of this study is to improve the understanding of the temporal aspects of flood risk through a combined analysis of the behavioral, engineering, and physical hazard aspects of flood risk. Additionally, the study aims to develop a new modeling approach for integrating behavior, policy, flood hazards, and engineering interventions. An agent‐based model (ABM) is used to analyze the influence of flood protection measures, individual behavior, and the occurrence of floods and near‐miss flood events on community flood risk. The ABM focuses on the following decisions and behaviors: dissemination of flood management information, installation of community flood protection, elevation of household mechanical equipment, and elevation of homes. The approach is place based, with a case study area in Fargo, North Dakota, but is focused on generalizable insights. Generally, community mitigation results in reduced future damage, and individual action, including mitigation and movement into and out of high‐risk areas, can have a significant influence on community flood risk. The results of this study provide useful insights into the interplay between individual and community actions and how it affects the evolution of flood risk. This study lends insight into priorities for future work, including the development of more in‐depth behavioral and decision rules at the individual and community level.     

The Risk of MTBE Relative to Other VOCs in Public Drinking Water in California

Ongoing publicity about methyl tertiary butyl ether (MTBE) suggests that this chemical is of greater concern than other contaminants commonly found in drinking water. The purpose of this article is to evaluate the available MTBE data in context with other volatile organic compounds (VOCs) that are detected in public drinking water sources in California. We find that of the 28 VOCs with a primary maximum contaminant level (MCL) in California, 21 were found in 50 or more drinking water sources from 1985 to 2002. Over the last 10 years, the most frequently detected VOCs were chloroform, tetrachloroethylene (PCE), and trichloroethylene (TCE), which were found in about 9-15% of all sampled drinking water sources. These same chemicals were found to have the highest mean detected concentrations over the last 5 years, ranging from 13 to 15 microg/L. Many VOCs were also found to routinely exceed state and federal drinking water standards, including benzene and carbon tetrachloride. By comparison, MTBE was found in approximately 1% of sampled drinking water sources for most years, and of those drinking water sources found to contain MTBE from 1998 to 2002, over 90% had detected concentrations below California's primary MCL of 13 microg/L. Relative to the other VOCs evaluated, MTBE has the lowest estimated California cancer potency value, and was found to pose one of the least cancer risks from household exposures to contaminated drinking water. These findings suggest that MTBE poses an insignificant threat to public drinking water supplies and public health in California, particularly when compared to other common drinking water contaminants.     

A Risk Assessment Model to Evaluate the Role of Fecal Contamination in Recreational Water on the Incidence of Cryptosporidiosis at the Community Level in Ontario

A quantitative microbial risk assessment model was developed to simulate the role of recreational water contact in the transmission of cryptosporidiosis in a model Ontario community. Stochastic simulations were based on plausible modes of contamination of a pool (literature derived), river (site-specific), and recreational lakes (literature derived). The highest estimated risks of infection were derived from the (highly contaminated) recreational lake scenario, considered the upper end for risk of infection for both children (10 infections per 1,000 swims [5‰: two infections per 1,000 swims; 95‰: three infections per 100 swims]) and adults (four infections per 1,000 swims [5‰: four infections per 1,000 swims; 95‰: one infection per 100 swims]). Simulating the likely  Cryptosporidium  oocyst concentration in a lane pool that a child would be exposed to following a diarrheal fecal release event resulted in the third highest mean risk of infection (four infections per 10,000 swims [5‰: three infections per 100,000; 95‰: 10 infections per 10,000 swims]). The findings from this study illustrate the need for systematic and standardized research to quantify  Cryptosporidium  oocyst levels in Canadian public pools and recreational beaches. There is also a need to capture the swimming practices of the Canadian public, including most common forms and frequency measures. The study findings suggest that swimming in natural swim environments and in pools following a recent fecal contamination event pose significant public health risks. When considering these risks relative to other modes of cryptosporidiosis transmission, they are significant.     

A Bayesian Approach to Integrated Ecological and Human Health Risk Assessment for the South River,Virginia Mercury‐Contaminated Site

We conducted a regional‐scale integrated ecological and human health risk assessment by applying the relative risk model with Bayesian networks (BN‐RRM) to a case study of the South River, Virginia mercury‐contaminated site. Risk to four ecological services of the South River (human health, water quality, recreation, and the recreational fishery) was evaluated using a multiple stressor–multiple endpoint approach. These four ecological services were selected as endpoints based on stakeholder feedback and prioritized management goals for the river. The BN‐RRM approach allowed for the calculation of relative risk to 14 biotic, human health, recreation, and water quality endpoints from chemical and ecological stressors in five risk regions of the South River. Results indicated that water quality and the recreational fishery were the ecological services at highest risk in the South River. Human health risk for users of the South River was low relative to the risk to other endpoints. Risk to recreation in the South River was moderate with little spatial variability among the five risk regions. Sensitivity and uncertainty analysis identified stressors and other parameters that influence risk for each endpoint in each risk region. This research demonstrates a probabilistic approach to integrated ecological and human health risk assessment that considers the effects of chemical and ecological stressors across the landscape.     

Source Credibility in Environmental Health – Risk Controversies: Application of Meyer's Credibility Index

This article applies an existing five-item index for measuring source credibility in the context of environmental health-risk controversy. Survey data were gathered in five upstate New York communities facing environmental health-risk issues. Analysis of the five case studies and a combined dataset (N = 870) show that the credibility index was consistently reliable across all applications. Use of the resulting index is demonstrated through a comparison of the credibility of the New York State Department of Health (active in each case), the industries associated with each case, and the newspaper providing coverage of each case. The credibility index was used to predict risk judgments in a structural equation model. Overall, the analysis demonstrated that the credibility index performed consistently well across the five cases and illuminated important differences in each. As such, the index should be a useful addition to many environmental health and risk communication studies.     

An Ecological Model for Quantitative Risk Assessment for Schistosomiasis: The Case of a Patchy Environment in the Coastal Tropical Area of Northeastern Brazil

We developed a stochastic model for quantitative risk assessment for the Schistosoma mansoni (SM) parasite, which causes an endemic disease of public concern. The model provides answers in a useful format for public health decisions, uses data and expert opinion, and can be applied to any landscape where the snail Biomphalaria glabrata is the main intermediate host (South and Central America, the Caribbean, and Africa). It incorporates several realistic and case‐specific features: stage‐structured parasite populations, periodic praziquantel (PZQ) drug treatment for humans, density dependence, extreme events (prolonged rainfall), site‐specific sanitation quality, environmental stochasticity, monthly rainfall variation, uncertainty in parameters, and spatial dynamics. We parameterize the model through a real‐world application in the district of Porto de Galinhas (PG), one of the main touristic destinations in Brazil, where previous studies identified four parasite populations within the metapopulation. The results provide a good approximation of the dynamics of the system and are in agreement with our field observations, i.e., the lack of basic infrastructure (sanitation level and health programs) makes PG a suitable habitat for the persistence and growth of a parasite metapopulation. We quantify the risk of SM metapopulation explosion and quasi‐extinction and the time to metapopulation explosion and quasi‐extinction. We evaluate the sensitivity of the results under varying scenarios of future periodic PZQ treatment (based on the Brazilian Ministry of Health's plan) and sanitation quality. We conclude that the plan might be useful to slow SM metapopulation growth but not to control it. Additional investments in better sanitation are necessary.     

Public Reliance on Risk Communication Channels in the Wake of a Cryptosporidium Outbreak

In the spring of 1993, about 39% of Milwaukee-area residents suffered through a nationally publicized illness brought about by cryptosporidium, a parasite that had infested the metropolitan drinking water supply. Our study, based on a telephone survey of 610 local adult residents, indicates that worry about becoming ill in the future with cryptosporidiosis relates more strongly and consistently to public reliance on, and use of, media for cryptosporidium information than do a range of risk perception and experience variables. We propose that more studies should take an audience-centered approach to understanding risk communication.     

Significance of Exposure Assessment to Analysis of Cancer Risk from Inorganic Arsenic in Drinking Water in Taiwan

The primary source of evidence that inorganic arsenic in drinking water is associated with increased mortality from cancer at internal sites (bladder, liver, lung, and other organs) is a large ecologic study conducted in regions of Southwest Taiwan endemic to Blackfoot disease. The dose-response patterns for lung, liver, and bladder cancers display a nonlinear dose-response relationship with arsenic exposure. The data do not appear suitable, however, for the more refined task of dose-response assessment, particularly for inference of risk at the low arsenic concentrations found in some U.S. water supplies. The problem lies in variable arsenic concentrations between the wells within a village, largely due to a mix of shallow wells and deep artesian wells, and in having only one well test for 24 (40%) of the 60 villages. The current analysis identifies 14 villages where the exposure appears most questionable, based on criteria described in the text. The exposure values were then changed for seven of the villages, from the median well test being used as a default to some other point in the village's range of well tests that would contribute to smoothing the appearance of a dose-response curve. The remaining seven villages, six of which had only one well test, were deleted as outliers. The resultant dose-response patterns showed no evidence of excess risk below arsenic concentrations of 0.1 mg/l. Of course, that outcome is dependent on manipulation of the data, as described. Inclusion of the seven deleted villages would make estimates of risk much higher at low doses. In those seven villages, the cancer mortality rates are significantly high for their exposure levels, suggesting that their exposure values may be too low or that other etiological factors need to be taken into account.     

Quantile Uncertainty and Value‐at‐Risk Model Risk

This article develops a methodology for quantifying model risk in quantile risk estimates. The application of quantile estimates to risk assessment has become common practice in many disciplines, including hydrology, climate change, statistical process control, insurance and actuarial science, and the uncertainty surrounding these estimates has long been recognized. Our work is particularly important in finance, where quantile estimates (called Value‐at‐Risk) have been the cornerstone of banking risk management since the mid 1980s. A recent amendment to the Basel II Accord recommends additional market risk capital to cover all sources of “model risk” in the estimation of these quantiles. We provide a novel and elegant framework whereby quantile estimates are adjusted for model risk, relative to a benchmark which represents the state of knowledge of the authority that is responsible for model risk. A simulation experiment in which the degree of model risk is controlled illustrates how to quantify Value‐at‐Risk model risk and compute the required regulatory capital add‐on for banks. An empirical example based on real data shows how the methodology can be put into practice, using only two time series (daily Value‐at‐Risk and daily profit and loss) from a large bank. We conclude with a discussion of potential applications to nonfinancial risks.     

Testing and Expanding a Model of Cognitive Processing of Risk Information

Scholars have begun to explore the role of modes of information processing and related audience characteristics in reactions to risky situations and risk information.((11, 12, 14, 17, 18, 20))"Information processing" concerns how people attend to and consider available information: systematic processors analyze messages and situations carefully, while heuristic processors skim and use cues (e.g., opinions of trusted reference groups) for quick judgments. This article uses scenarios about a semi-hypothetical industrial facility, in particular risk comparisons being considered by its manager for inclusion in a talk to the community, to explore the impact of information processing. Information insufficiency, self-assessed capacity to understand information, and information-seeking propensities are tested for potential effects on information processing about industrial risks by people living near industry. As well as testing established models, this article explores the additional explanatory value of involvement, relevance, and ability (Earle et al., 1990) and objective knowledge. Both existing model variables and new ones have significant effects on information seeking and information processing in this case, and partly confirm earlier results. Trumbo((17,18)) found that heuristic processors saw lower risk and systematic processors higher risk from suspected cancer clusters. In this study, reporting knowledge about local industrial risks as insufficient for one's purposes and self-reported avoidance of such information both raised ratings of the facility's risk and lowered ratings of its acceptability. Neither type of information processing significantly affected risk or acceptability judgments, but both increased risk ratings and heuristic processing had more effect than systematic processing. Positive ratings of risk comparisons' clarity and meaningfulness decreased risk and increased acceptability ratings, dominated other information variables in predictive power, and exceeded risk, benefit, and trust in contribution to acceptability judgments. Despite differences across studies in designs and variables, and the embryonic development of appropriate (self-reported) measures for use in field surveys, these results confirm the potential value of further research in how information seeking and processing affect risk beliefs and reactions to risk communications.     

One Agency's Use of Risk Assessment and Risk Communication1

Few organizations have the courage to evaluate their own use of risk assessment (identifying hazards and estimating their probability and magnitude) and risk communication (interacting with internal and external stakeholder groups about risks). The USDA Animal and Plant Health Inspection Service (APHIS) wants to enhance its overall risk analysis process for managing a wide range of risks to animals, plants, and human health. We gathered survey data for a baseline of APHIS professionals’ understanding and use of risk assessment and risk communication. APHIS professionals spend a surprisingly large share of their time communicating about risks. They perceive that risk estimates influence decisions, but that risk estimates should have more influence. Respondents reported little opposition to APHIS risk management decisions, and little use of channels such as USDA Extension Service for disseminating risk messages. Substantial variance across responses is explained mostly by differences in the roles of the 11 work units (now 10) within the agency. Location also contributes to the variance. Demographic variables seem less important.