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By P. Rozhov. Franklin University. 2019.

In major outbreaks of enteroviral origin , there has been a low incidence of a polio-like paralysis , including cranial nerve palsies , lumbosacral radiculomyelitis and lower motor neuron paralysis . Adenoviral hemorrhagic conjuctivitis was first recognized in Ghana in 1969 and Indonesia in 1970; numerous epidemics have occurred since then in tropical areas of Asia , Africa , Central and South America , the Caribbean , the Pacific islands and parts of Florida and Mexico . An outbreak in American Samoa in 1986 due to coxsackievirus A24 variant affected an estimated 48% of the population . Mode of transmission—Direct or indirect contact with discharge from infected eyes. Person-to-person transmission is most noticeable in families, where high attack rates often occur. Adenovirus can be transmit- ted in poorly chlorinated swimming pools and has been reported as “swimming pool conjunctivitis”; it is also transmitted through respiratory droplets. Period of communicability—Adenovirus infections may be com- municable up to 14 days after onset, picornavirus at least 4 days after onset. Personal hygiene should be emphasized, including use of non-shared towels and avoidance of overcrowding. Eye clinics must ensure high level disinfection of potentially contaminated equipment. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory report of epidem- ics; no case report, Class 4 (see Reporting). Epidemic measures: 1) Organize adequate facilities for the diagnosis and symptom- atic treatment of cases. Identification—In the newborn, an acute conjunctivitis with pu- rulent discharge, usually recognized within 5–12 days after birth. The acute stage usually subsides spontaneously in a few weeks; inflammation of the eye may persist for more than a year if untreated, with mild scarring of the conjunctivae and infiltration of the cornea (micropannus). In children and adults, an acute follicular conjunctivitis is seen typically with preauricular lymphadenopathy on the involved side, hyperaemia, infiltration and a slight mucopurulent discharge, often with superficial corneal involvement. In adults, there may be a chronic phase with scant discharge and symptoms that sometimes persist for more than a year if untreated. The agent may cause symptomatic infection of the urethral epithelium in men and women and the cervix in women, with or without associated conjunctivitis. Occurrence—Sporadic cases of conjunctivitis are reported world- wide among sexually active adults. Among adults with genital chlamydial infection, 1 in 300 develops chlamydial eye disease. Mode of transmission—Generally transmitted during sexual inter- course; the genital discharges of infected people are infectious. In the newborn, conjunctivitis is usually acquired by direct contact with infec- tious secretions during transit through the birth canal. The eyes of adults become infected by the transmission of genital secretions to the eye, usually by the fingers. Older children may acquire conjunctivitis from infected newborns or other household mem- bers; they should be assessed for sexual abuse as appropriate. Outbreaks reported among swimmers in nonchlorinated pools have not been con- firmed by culture and may be due to adenoviruses or other known causes of “swimming pool conjunctivitis. Incubation period—In newborns, 5–12 days, ranging from 3 days to 6 weeks; adults 6–19 days. Period of communicability—While genital or ocular infection persists; carriage on mucous membranes has been observed as long as 2 years after birth. Susceptibility—There is no evidence of resistance to reinfection, although the severity of the disease may be decreased. Treatment of cervical infection in pregnant women will prevent subsequent transmission to the infant. The method of choice is either a single applica- tion into the eyes of the newborn of povidone-iodine (2. All methods give comparable results in preventing gonococcal conjunctivitis; in field studies povidone-iodine was significantly more effective in pre- venting neonatal eye infections. Ocular prophylaxis does not prevent nasopharyngeal colonization and risk of sub- sequent chlamydial pneumonia. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Case report of neonatal cases obligatory in many countries, Class 2 (see Reporting). Infected adults should be investigated for evidence of ongoing infec- tion with gonorrhoea or syphilis. Epidemic measures: Sanitary control of swimming pools; ordinary chlorination suffices. They cause disseminated disease in newborns; there is evidence suggesting their involvement in the etiology of juvenile onset insulin-depen- dent diabetes. Identification—Vesicular pharyngitis (herpangina) is an acute, self-limited, viral disease characterized by sudden onset, fever, sore throat and small (1–2 mm), discrete, greyish papulovesicular pharyngeal lesions on an erythematous base, gradually progressing to slightly larger ulcers. These lesions usually occur on the anterior pillars of the tonsillar fauces, soft palate, uvula and tonsils, and may persist 4–6 days after the onset of illness. Vesicular stomatitis with exanthem (hand, foot and mouth disease) differs from vesicular pharyngitis in that oral lesions are more diffuse and may occur on the buccal surfaces of the cheeks and gums and on the sides of the tongue. Papulovesicular lesions, which may persist from 7 to 10 days, also occur commonly as an exanthem, especially on the palms, fingers and soles; maculopapular lesions occasionally appear on the buttocks. Although the disease is usually self-limited, rare cases have been fatal in infants. Acute lymphonodular pharyngitis also differs from vesicular pharyngitis in that the lesions are firm, raised, discrete, whitish to yellowish nodules, surrounded by a 3–6 mm zone of erythema. They occur predominantly on the uvula, anterior tonsillar pillars and posterior pharynx, with no exanthem. These diseases are not to be confused with vesicular stomatitis caused by the vesicular stomatitis virus, normally of cattle and horses, which in humans usually occurs among dairy workers, animal husbandrymen and veterinarians. Foot-and-mouth disease of cattle, sheep and swine rarely affects laboratory workers handling the virus; however, humans can be a mechanical carrier of the virus and the source of animal outbreaks. A virus not serologically differentiable from coxsack- ievirus B-5 causes vesicular disease in swine, which may be transmitted to humans. Differentiation of the related but distinct coxsackievirus syndromes is facilitated during epidemics. Virus may be isolated from lesions and nasopharyngeal and stool specimens through cell cultures and/or inocu- lation to suckling mice. Since many serotypes may produce the same syndrome and common antigens are lacking, serological diagnostic proce- dures are not routinely available unless the virus is isolated for use in the serological tests. Infectious agents—For vesicular pharyngitis, coxsackievirus, group A, types 1–10, 16 and 22. For vesicular stomatitis with or without exanthem (hand, foot and mouth disease), coxsackievirus, group A, type A16 predominantly and types 4, 5, 9 and 10; group B, types 2 and 5; and (less often) enterovirus 71. Occurrence—Probably worldwide for vesicular pharyngitis and vesicular stomatitis, both sporadically and in epidemics; maximal incidence in summer and early autumn; mainly in children under 10, but adult cases (especially young adults) are not unusual. Isolated outbreaks of acute lymphonodular pharyngitis, predominantly in chil- dren, may occur in summer and early autumn. Mode of transmission—Direct contact with nose and throat discharges and feces of infected people (who may be asymptomatic) and by aerosol droplet spread; no reliable evidence of spread by insects, water, food or sewage. Incubation period—Usually 3–5 days for vesicular pharyngitis and vesicular stomatitis; 5 days for acute lymphonodular pharyngitis. Period of communicability—During the acute stage of illness and perhaps longer, since viruses persist in stool for several weeks. Immunity to the specific virus is probably acquired through clinical or inapparent infection; duration unknown. Second attacks may occur with group A coxsackievirus of a different serological type. Preventive measures: Limit person-to-person contact, where practicable, by measures such as crowd reduction and ventila- tion. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory report of epidem- ics in some countries; no case report, Class 4 (see Reporting). Give careful atten- tion to prompt handwashing when handling discharges, feces and articles soiled therewith. Epidemic measures: Give general notice to physicians of increased incidence of the disease, together with a description of onset and clinical characteristics. Isolate diagnosed cases and all children with fever, pending diagnosis, with special attention to respiratory secretions and feces. Identification—An acute or subacute viral myocarditis or pericar- ditis occurring (occasionally with other manifestations) as a manifestation of infection with enteroviruses, especially group B coxsackievirus. Heart failure may be progressive and fatal, or recovery may take place over a few weeks; some cases run a relapsing course over months and may show residual heart damage. In young adults, pericarditis is the more common manifes- tation, with acute chest pain, disturbance of heart rate, and often dyspnoea. It may mimic myocardial infarction but is frequently associated with pulmonary or pleural manifestations (pleurodynia). The disease may be associated with aseptic meningitis, hepatitis, orchitis, pancreatitis, pneumonia, hand, foot and mouth disease, rash or epidemic myalgia (see Myalgia, epidemic). Serological studies or virus isolation from feces usually help diagnosis, but such results are inconclusive; a significant rise in specific antibody titres is diagnostic. Virus is rarely isolated from pericardial fluid, myocar- dial biopsy or postmortem heart tissue; such an isolation provides a definitive diagnosis. Infectious agents—Group B coxsackievirus (types 1–5); occasion- ally group A coxsackievirus (types 1, 4, 9, 16, 23) and other enteroviruses. Occurrence—An uncommon disease, mainly sporadic, but in- creased during epidemics of group B coxsackievirus infection. Institu- tional outbreaks, with high case-fatality rates in newborns, have been described in maternity units. Reservoir—Mode of transmission, Incuba- tion period, Period of communicability, Susceptibility and Methods of control—See Epidemic myalgia. Identification—Infection with Cryptococcus starts through inhala- tion into the lungs, but tends to hematogenic spread to the brain, usually presenting as a subacute or chronic meningitis; infection of lungs, kidneys, prostate and bone may occur. Occasionally, the causal agent Cryptococcus neoformans may act as an endobronchial saprophyte in patients with other lung diseases. Diagnosis is confirmed through histopathology or culture (media containing cycloheximide inhibit the agent and should not be used). Mayer mucicarmine stains most crypto- cocci in tissue deep red, aiding histopathological diagnosis. The perfect (sexual) states of these fungi are called Filobasidiella neoformans and F. Preventive measures: While there have been no case clusters traced to exposure to pigeon droppings, the ubiquity of C. Asymptomatic infections are common and constitute a source of infection for others. The major symptom in human patients is diarrhea, which may be profuse and watery, preceded by anorexia and vomiting in children. Symptoms often wax and wane but remit in less than 30 days in most immunologically healthy people. Symptoms of cholecystitis may occur in biliary tract infections; the relationship between respiratory tract infec- tions and clinical symptoms is unclear. Diagnosis is generally through identification of oocysts in fecal smears or of life cycle stages of the parasites in intestinal biopsy sections. Oocysts are small (4–6 micrometers) and may be confused with yeast unless appropriately stained. Most commonly used stains include auramine- rhodamine, a modified acid-fast stain, and safranin-methylene blue. A fluorescein-tagged monoclonal antibody is useful for detecting oocysts in stool and in environmental samples. Infection with this organism is not easily detected unless looked for specifically. Serological assays may help in epidemiological studies, but it is not known when the antibody appears and how long it lasts after infection. Infectious agent—Cryptosporidium parvum, a coccidian proto- zoon, is the species associated with human infection. Cryptosporidium oocysts have been identified in human fecal specimens from more than 50 countries. Children under 2, animal handlers, travellers, men who have sex with men and close personal contacts of infected individuals (families, health care and day care workers) are particularly prone to infection. Outbreaks have been reported in day care centers around the world, and have also been associated with: drinking water (at least 3 major outbreaks involved public water supplies); recreational use of water including waterslides, swimming pools and lakes; and consump- tion of contaminated beverages. Mode of transmission—Fecal-oral, which includes person-to-per- son, animal-to-person, waterborne and foodborne transmission. The para- site infects intestinal epithelial cells and multiplies initially by schizogony, followed by a sexual cycle resulting in fecal oocysts that can survive under adverse environmental conditions for long periods of time. Oocysts are highly resistant to chemical disinfectants used to purify drinking water. Incubation period—Not known precisely; 1–12 days is the likely range, with an average of about 7 days. Period of communicability—Oocysts, the infectious stage, ap- pear in the stool at the onset of symptoms and are infectious immediately upon excretion. Excretion continues in stools for several weeks after symptoms resolve; outside the body, oocysts may remain infective for 2–6 months in a moist environment.

As you steadfastly and consistently con- template the image you see in the mirror , you are metamorphosed into the image of that glory you see in the mirror . Romans 8:21 , “Because the creature itself also shall be delivered from the bondage of corruption into the glorious liberty of the children of God . Recreated For Health The moment you were born again , the life you came with from your mother’s womb ceased to reign in your being; a new life from God took over . Paul said in 2 Corinthians 5:17 , “If any man is in Christ he is a new creation…” he’s a new species of being . He was made a living soul , but the second Adam - Jesus - was made a life-giving spirit . Verse 46, “Howbeit that was not first which is spiritual, but that which is natural and afterward that which is spiritual. The first Adam came under the influence of the devil, hence the influence of diseases, after His fall. Divine Health Is Now Yours When you were recreated with the life of God, Recreated For Health you were recreated in divine health. The fallen nature of the first Adam came with sickness and could be influenced by it, but the nature of God, which you have now received, came with life. A lot of times we don’t understand this and we turn back to live on the plane of the ordinary man, but you can stay in health. Christ Alive In You Colossians 1:27, “To whom God would make known what is the riches of the glory of this mystery among the Gentiles; which is Christ in you, the hope of glory:” Christ alive in you, living in your body, is enough to let you know that sickness is not part of God’s plan for you. At the end, Job repented and said, “I have heard of thee by the hearing of the ear: but now mine eye seeth thee. Until you have that revelation of eternal life affecting your body you will not be able to live in divine health. The Bible says this corruptible must put on incorruptible and this mortality must put on immortality (1 Corinthians 15:52). Yes, for them in the Old Testament the blood sustained life, but for the new creature in Christ, there is a higher law at work. Writing about Jesus, John said, “But as many as received him, to them gave he power to become the sons of God, even to them that believe on his name: Which were born, not of blood, nor of the will of the flesh, nor of the will of man, but of God” (John 1:12-13). We experienced a spiritual re- birth, the new life in our spirit is not dependent on blood. We were born by the Spirit of God, and this life in our spirits has affected our human body, such that even our human body is no longer dependent on the blood running in it. Living By The Faith Of Jesus Galatians 2:20, “I am crucified with Christ: nev- ertheless I live; yet not I, but Christ liveth in me: and the life which I now live in the flesh I live by the faith of the Son of God, who loved me, and gave himself for me. He didn’t go to the Cross for Him- The Life of The Blood or The Life of The Spirit self. Jesus took responsibil- ity for our errors and so He died for us and was raised again with a new kind of life. And the life that we now live in the body, we live by the faith of the Son of God. And the resur- rection life is not dependent on blood, but on the power of an endless life. The life we now live in the body we live by the faith of the Son of God who loved us and gave Himself for us. He that believeth and is baptized shall be saved; but he that believeth not shall be damned. The Lord was showing them a mystery, telling them there’s a new class of men arriving on the scene and they will be known by the signs that follow them. They shall cast out devils, they shall speak with new tongues, they shall take up serpents and if they drink any deadly thing it shall not hurt them. The Life of The Blood or The Life of The Spirit Romans 8:11, “But if the Spirit of him that raised up Jesus from the dead dwell in you, he that raised up Christ from the dead shall also quicken your mortal bodies by his Spirit that dwelleth in you. We haven’t understood this yet but we need to, because, the Bible says, “Through knowledge shall the just be delivered. God’s people suffer because of lack of knowledge, so they go on in pain, sickness and deprivation. But when the knowledge of the Word of God takes possession of the human spirit, something new happens. You don’t claim sickness from the devil, rather, you cast out sickness, commanding it to leave in the Name of Jesus. Romans 8:9, “But ye are not in the flesh, but in the Spirit, if so be that the Spirit of God dwell in you. You’re not con- trolled any longer by your sensory perceptions, the voice of your body. Those who behave according to their sight, according to their feeling, what they hear from outside, what they taste, what they smell. The New Discovery The world is about to make some of the great- est discoveries they’ve ever made from its beginning to this time. Some scientists have reported their findings that there seems to be a difference in the blood group of those who are born again and the rest of the world. The reason He has made you so is so you can show forth the praises and strength of Him who has called you out of darkness into His marvellous light. You need to read this from The Amplified Bible: “But you are a chosen race, a royal priesthood, a dedi- cated nation, [God’s] own purchased, special people, that you may set forth the wonderful deeds and dis- play the virtues and perfections of Him Who called you out of darkness into His marvelous light. He that hath the Son hath life; and he that hath not the Son of God hath not life. These things have I writ- ten unto you that believe on the name of the Son of The Impact of Zoe on The Human Body God; that ye may know that ye have eternal life, and that ye may believe on the name of the Son of God. It is a Greek word better translated ‘the essence of divinity’ - the life that if a man would have he would live forever. Having Zoë through Christ means life for your spirit, life for your soul and life for your body. The Bible says, “But we have these treasures in earthen vessels, that the excel- lency of the power may be of God and not of us” (2 Corinthians 4:7). John 3:16, “For God so loved the world, that he gave his only begotten Son, that whosoever believeth in him should not perish, but have everlasting life. It is another way of saying to the devil, “Don’t touch this one, he has been separated unto life. The child gets the blood from the father through the sperm, which is the carrier of life. When you look at 1 Peter 1:23 in this context, it becomes strongly sug- The Impact of Zoe on The Human Body gestive of something. There is a perishable sperm - you can grind a man’s sperm to death; a plant’s seed can be ground to death, but the sperm of God, by which you were born again, is imperishable and in- destructible, Hallelujah! When you were born again it was the seed of God that came to you and produced life in you. If truly we have God’s life (Zoë) in us, that brings life to our spirit, soul and body, where then is the place for sickness? No wonder Isaiah prophesied concerning us, saying, “Those that live therein (in Zion) shall not say, “I am sick”” (Isaiah 33:24). You can have your life marked in the right direction only; the direction of success, prosperity and the good life. The epidemic was so contagious that mere touching of those already in- fected could lead to an infection. When asked about it, he replied that another kind of life was at work in him and that if the disease germs came in contact with his body, this life in him would burn them up and destroy them. They took a sample containing these germs and dropped some on the back of his hand. They actually viewed his hand underneath a microscope to ensure the germ cells were alive. After a few hours, they checked under the microscope again and the germ The Impact of Zoe on The Human Body cells had stopped moving. Everyone there looked on at him, expect- ing him to swell or suddenly fall down dead. But Paul just shook off the viper into the fire and no harm came upon him (Acts 28:1-6). When you are Zoë-conscious, no germ cell, no matter what it is called, can have a home in your body or dominate your body. Mark 1:40, “And there came a leper to him, be- seeching him, and kneeling down to him, and saying unto him, If thou wilt, thou canst make me clean. When he saw Jesus he went to Him, bowed down and worshipped Him, saying, “Lord if thou wilt, thou canst make me clean. Master, I have brought unto thee my son, which hath a dumb spirit; And wheresoever he taketh him, he teareth him: and he foameth, and gnasheth with his teeth, and pineth away: and I spake to thy dis- ciples that they should cast him out; and they could not. And ofttimes it hath cast him into the fire, and into the waters, to destroy him: but if thou canst do any thing, have compassion on us, and help us” (Mark 9: 17,18,22). More often, people ask the leper’s question, who questioned not God’s abil- ity, but His willingness to heal. They even know He’s done it for others and can relate the testimonies of other people If Thou Wilt... He was not only sick in his body, he was an outcast, isolated from the society because of his contagious disease. But he had heard of Jesus and was desperate enough to want to find out if this Teacher from Nazareth would want to do something about his condition. I believe that day He must have known He was answering the ques- tion in the heart of not only people who were then present but also that of generations to come. With a lot of com- passion, He stretched forth His hand, touched the leper and said, “I will: be thou clean” (Mark 1:41). If you read the next verse you will discover that the man actually got healed as soon as Jesus spoke the word, not as soon as He touched him. Verse 42, “And as soon as he had spoken, im- mediately the leprosy departed from him, and he was cleansed. There is a record of another sick man who didn’t even have enough sense to know it was the Creator of the universe who was standing before him. Before he could finish, the Mas- ter told him, “Rise, take up thy bed, and walk” (John 5:8). During one of our healing crusades - Night of Bliss - a young man came up to share his testimony. Of course, that woke him up to discover he had been instantly healed by the power of God! God said, “Beloved, I wish above all things that thou mayest prosper and be in health, even as thy soul prospereth” (3 John 2). If society has made you an outcast because of your sickness; if your infirmity has isolated you from the mainstream of life, from living life in health and abundance; if you’re sick and wondering if God can ever do something about it, I want you to know that God is more willing to heal you than you are willing to be healed. Just like the disciples asked Jesus concerning the blind man, “Who did sin, this man, or his parents that he was born blind? God Somebody said, “God put that sickness on me because, Knid He knew if I was not sick I would have done such-and- of such. The same fellow who said God put the sick- ness on him to make him humble goes straight to the doctor to take away what God put on him to make him humble. He says it’s God’s will to make him sick because God wants him to be humble, but then he starts taking drugs to take away what God put on him to make him humble. Some people give the examples of the Egyp- tians to illustrate that God actually put sickness on people to make them humble. The only problem is those people have forgotten that the Egyptians were not the people of God. The Bible lets us know there are indeed clay pots fitted for destruc- tion, but this doesn’t refer to the children of God! Some people are so hypocritical, they will criti- cize any minister who preaches prosperity and di- vine healing. Never criticize a christian or a minister of the gospel who teaches divine healing or prosper- ity. The same people who criticize such ministers would go to work six days a week but wouldn’t open their Bibles or pray just as often. In fact, if such people had a fever during the week, they would still drag themselves to work. And just the one time they come to Church, they say, “I wish the Pastor would talk about righteous- ness and holiness and leave prosperity and divine healing out. No one can pretend to go to work every- day of the week just because he loves his boss or be- cause he loves the nation. Do you know after Jesus healed a man who had had an infirmity for thirty-eight years at the pool of Bethesda, the Pharisees complained? Accord- ing to their understanding, no work was supposed to be done on a Sabbath day. And because Jesus told the man, “Rise, take up thy bed, and walk” they consid- ered carrying his bed to be work. This man had suffered for thirty-eight long years; no one remembered the sabbath all that time. It wasn’t a day of sitting at home, it was a day of rejoicing, a day of rest from trouble, rest from worry and pain and rest from disease and infirmity of the body. Nobody ever told that man the truth, and just on the day Jesus gave him rest from pain, they all came shouting, “It’s the Sabbath! As long as you’re sick and poor, they will extend their sympathy, but the moment you start talking the same as God, con- fessing you’re the healed in Christ, then they take note of you and criticize you. We were not even born when Jesus went to suffer for our sins on the Cross and took our pains upon Himself. What more could our God have don to demonstrate His desire for our complete well being?

Proper and consistent procedures for counting and identifying target colonies will be followed , as described in Myers and Sylvester (1997) . Have a second analyst check calculations of bacterial concentrations in water for errors . For coliphage , Cryptosporidium , Giardia , and enteric virus samples , equipment and field blanks are used to determine sampling and analytical bias . An equipment blank is a blank solution (sterile buffered water) subjected to the same aspects of sample collection , processing , storage, transportation, and laboratory handling as an environmental sample, but it is processed in an office or laboratory. Waterborne Diseases ©6/1/2018 220 (866) 557-1746 Field blanks are the same as equipment blanks except that they are generated under actual field conditions. At a minimum, the number of field blanks should equal 5 percent of the total number of samples collected. Five percent of samples collected for bacterial and viral indicators (total coliforms, E. For streamwater samples, concurrent replicates to estimate sampling variability are collected by alternating subsamples in each vertical between two collection bottles. For ground-water samples, sequential replicates are collected one after another into separate sterile bottles. Concurrent and sequential replicates are then analyzed in duplicate (split replicates) to estimate analytical variability. To assess analytical bias of the sampling and analytical method, 2 to 5 percent of the samples collected for enteric virus should be field matrix spikes. Because of the variability in the performance of Method 1623 for recovery of Cryptosporidium and Giardia, each sample will be collected in duplicate—one will be a regular sample and the other a matrix spike. Quality Assurance and Quality Control in the Laboratory The following criteria may be used to evaluate each production analytical laboratory: (1) appropriate, approved, and published methods, (2) documented standard operating procedures, (3) approved quality-assurance plan, (4) types and amount of quality-control data fully documented and technical defensible, (5) participation in the standard reference sample project (6) scientific capability of personnel, and (7) appropriate laboratory equipment. The microbiology laboratories must follow good laboratory practices—cleanliness, safety practices, procedures for media preparation, specifications for reagent water quality—as set forth by American Public Health Association (1998) and Britton and Greeson (1989). Reference cultures are used by the central laboratory to evaluate the performance of the test procedures, including media and reagents. Waterborne Diseases ©6/1/2018 221 (866) 557-1746 Because contamination of samples from coliphage during the analytical procedure is highly probable (Francy and others, 2000), a negative control of host and sterile buffered water is run concurrently with each batch of samples. In addition, to ensure that the method is being executed properly, a positive-control sewage sample is run with each batch of samples. A laminar flow safety hood is recommended for processing the samples for coliphage analysis. Alternatively, a separate coliphage room may be established to discourage laboratory contamination during the analytical process. An ultraviolet light is installed and operated for 8 hours every night in the safety hood or coliphage room to reduce contamination. Waterborne Diseases ©6/1/2018 222 (866) 557-1746 Disinfection Byproduct Regulations Drinking water chlorination has contributed to a dramatic decline in waterborne disease rates and increased life expectancy in the United States. Largely because of this success, many Americans take it for granted that their tap water will be free of disease-causing organisms. In recent years, regulators and the general public have focused greater attention on potential health risks from chemical contaminants in drinking water. It is now recognized that all chemical disinfectants form some potentially harmful byproducts. Thus, it is important that disinfection not be compromised in attempting to control such byproducts. Most water systems are meeting these new standards by controlling the amount of natural organic matter prior to disinfection, while ensuring that microbial protection remains the top priority. For this reason, The American Academy of Microbiology (Ford and Colwell, 1996) has recommended, the health risks posed by microbial pathogens should be placed as the highest priority in water treatment to protect public health. A report published by the International Society of Regulatory Toxicology and Pharmacology (Coulston and Kolbye, 1994) stated “The reduction in mortality due to waterborne infectious diseases, attributed largely to chlorination of potable water supplies, appears to outweigh any theoretical cancer risks (which may be as low as zero) posed by the minute quantities of chlorinated organic chemicals reported in drinking waters disinfected with chlorine. Coagulation and Clarification Most treatment plants optimize their coagulation process for turbidity (particle) removal. However, coagulation processes can also be optimized for natural organic matter removal with higher doses of inorganic coagulants (such as alum or iron salts), and optimization of pH. Absorption Activated carbon can be used to absorb soluble organics that react with disinfectants to form byproducts. Membrane Technology Membranes, used historically to desalinate brackish waters, have also demonstrated excellent removal of natural organic matter. Membrane processes use hydraulic pressure to force water through a semi-permeable membrane that rejects most contaminants. Much less is known about the byproducts of these alternatives than is known about chlorination byproducts. Furthermore, each disinfection method has other distinct advantages and disadvantages. Waterborne Diseases ©6/1/2018 225 (866) 557-1746 Waterborne Diseases ©6/1/2018 226 (866) 557-1746 Common Water Quality and Sampling Questions and Review These statements will be more explained in the previous chapters. The regulations call for ao minimum of five samples for the month from any system that has positive sample results. Small systems that take only one sample per month have to take four (4) repeats when they get a total coliform positive test result. If any system has to take repeat samples, it must also take a minimum of five (5) routine samples the following month. Small systems that normally take less than 5 samples/month will have to increase the number to 5 samples. They can return to normal sampling schedules the following month if no repeats are required. Proper sampling techniques are extremely important in obtaining accurate water quality information. An improperly taken coliform sample may indicate bacteriological contamination of your water when the water is actually safe. The sampling point must be a faucet from which water is commonly taken for public use. It should not be a faucet that leaks, permitting water to run over the outside of the faucet. If an outside faucet must be used, disconnect any hoses or other attachments and be sure to flush the line thoroughly. Do not dip the bottle in reservoirs, spring boxes or storage tanks in order to collect the sample. Gallons per minute- Million Gallons a Day - Total Trihalomethanes – Pounds Per Square Inch –Haloacetic acids - Nephelometric turbidity unit -Milligrams Per Liter 4. Milligram per liter: Milligram per liter of substance and part per million are equals amounts in water. One ppb represents one microgram of something per liter of water (ug/l), or one microgram of something per kilogram of soil (ug/kg). Parts per million (ppm) or Milligrams per liter (mg/l) - one part per million corresponds to one minute in two years or a single penny in $10,000. Parts per billion (ppb) or Micrograms per liter - one part per billion corresponds to one minute in 2,000 years, or a single penny in $10,000,000. Parts per trillion (ppt) or Nanograms per liter (nanograms/l) - one part per trillion corresponds to one minute in 2,000,000 years, or a single penny in $10,000,000,000. Presence-absence Test: Presence-Absence Broth is used for the detection of coliform bacteria in water treatment plants or distribution systems using the presence-absence coliform test. Physical Characteristics of Water: A characteristic of water defined by the temperature, turbidity, color, taste, and odor of the water. Routine Sample: Samples collected on a routine basis to monitor for contamination. Repeat Sample: Short answer… Samples collected following a ‘coliform present’ routine sample. The number of repeat samples to be collected is based on the number of routine samples you normally collect. Waterborne Diseases ©6/1/2018 228 (866) 557-1746 Anytime a microbiological sample result comes back positive, indicating the presence of total or fecal coliform/ E. The two samples must be taken upstream and downstream of the original site (within five service connections). These repeat samples must be taken within 24 hours of notification of positive results. The regulations also state that when repeats are taken the minimum number of samples is raised to five for the month. A system that collects just one sample a month must collect four repeat samples, when the sample is positive, in order to have five samples as required. Whenever a system has to take repeat samples, a minimum of five routine samples must also be submitted the following month. This is only an issue for systems that normally turn in four or fewer samples each month. If the five samples are negative the system can return to its normal sampling schedule the next month. Small systems that have fewer than four sampling sites have a problem complying with the “upstream and downstream” aspects of the repeat sampling requirements. In this case, samples should be taken at as many separate sites as possible and then wait a minimum of 2 hours before resampling enough sites to get the required number of samples. Treatment technique: An enforceable procedure or level of technical performance which public water systems must follow to ensure control of a contaminant. Action level: The level of lead or copper which, if exceeded, triggers treatment or other requirements that a water system must follow. What does the membrane filter test analyze with regards to bacteriological sampling? Membrane Filter Technique: A standard test used for measuring coliform numbers (quantity) in water is the membrane filter technique. This technique involves filtering a known volume of water through a special sterile filter. These filters are made of nitrocellulose acetate and polycarbonate, are 150 μm thick, and have 0. A grid pattern is printed on these filter disks in order to facilitate colony counting. The filter is then carefully removed, placed in a sterile petri plate on a pad saturated with a liquid medium, and incubated for 20-24 hours at 37°C. One assumes that each bacterium trapped on the filter will then grow into a separate colony. By counting the colonies one can directly determine the number of bacteria in the water sample that was filtered. Total coliform colonies will be pink to dark red in color and will appear to have a golden green color. What do the following terms mean in relation to drinking water quality: disinfection, pathogenic, toxic, pH, aesthetic, culinary and potable. Disinfection: The chemical process of killing or inactivating most microorganisms in water. These include bacteria, viruses, cysts and anything capable of causing disease in humans, like cryptosporidiosis, typhoid, cholera and so on. There are other organisms that do not create disease, these are called non-pathogenic organisms. A pH of less than 7 is on the acid side of the scale with 0 as the point of greatest acid activity. A pH of more than 7 is on the basic (alkaline) side of the scale with 14 as the point of greatest basic activity. For example, the acidity of a sample with a pH of 5 is ten times greater than that of a sample with a pH of 6. A difference of 2 units, from 6 to 4, would mean that the acidity is one hundred times greater, and so on. Aesthetic: Attractive or appealing water or things in water that will not make you sick but may appear to change the water’s color or taste. Potable: Water that is free of objectionable pollution, contamination, or infective agents. Hardness: Water that contains high amounts of dissolved minerals, specifically calcium and magnesium. Ion Exchange: A method of water softening where hardness causing ions are exchanged with sodium ions; also effective in removing many inorganic contaminants such as nitrates, copper, and lead; and treating aesthetic water problems. What is Escherichia Coliform and what does it indicate in relation to drinking water? Waterborne Diseases ©6/1/2018 230 (866) 557-1746 Total coliform, fecal coliform, and E. If total coliform is present, the sample will also be tested for either fecal coliform or E. Hydrogen sulfide is a gas which, when dissolved in water, gives it a “rotten egg” odor. Chlorination will remove this gas from the water but the effectiveness of the chlorine for disinfection is lessened. When Hydrogen sulfide reacts with chlorine, it produces Sulfuric acid and elemental Sulfur: It is therefore recommended that aeration be applied prior to the addition of chlorine for the most effective disinfection. Why is it important to know what the turbidity of the water is when using chlorine?

What it does mean invariably is that her- is extremely important for sexually active individ- pes is in its active phase . Symptoms of recurrent uals to understand that genital herpes can be trans- episodes tend to be milder than those of the first mitted even if the infected partner has no sores or episode and last about a week . It should be emphasized that people with oral herpes can transmit the infection to the Prevention genital area of a partner during oral–genital sex . A Before and during an outbreak , herpes is conta- third route of transmission is through a herpes- gious . It is most contagious when the virus is repli- infected individual who transmits the disease with cating externally before an outbreak and during an no concern for his or her victims . The not attribute their symptoms to genital herpes at patient who takes the drug before lesions appear the time of transmission . During an active herpes makes more significant gains , and , in some cases , episode, people with genital herpes should take early preventive medication forestalls formation of steps to speed healing and to prevent spread of the lesions altogether. The patient protection, but no one should count on these to takes a small dose of antiviral medication daily for provide 100 percent protection because viral long periods. Typically, those on suppressive ther- shedding, and thus exposure, can occur when a apy dramatically reduce their symptom recurrence, herpes lesion (sometimes invisible to the naked and in about one-fourth, there are no recurrences eye) is not totally covered by the condom. Often, the physician treating the herpes suf- partner has genital herpes, abstain from sex when ferer stops suppressive therapy once a year to symptoms are present and use latex condoms assess the need for the medication. Recent research suggests yet another advantage An individual with herpes sores on the lips can of suppressive therapy—a 95 percent reduction in spread herpes to the lips of another person through days per year of viral shedding and risk of trans- kisses. For that reason, many cases of genital transmission can be completely prevented by use herpes are caused by herpes type 1. A patient who takes Treatment either drug can reduce the duration and severity of For herpes, there is no quick fix, nor is there a symptoms during a first episode and speed healing cure. Medications called antiviral drugs can, how- during recurrences and prodrome (when there are ever, attack the virus and give those afflicted with warning signs and symptoms). They work espe- this disease some relief, helping to reduce the cially well when initiated within 24 hours of onset duration and severity of symptoms. Research shows that daily five times a day for a first episode and usually 400 use of antiviral therapy dramatically lessens the mg is taken three times a day for treatment of rate of asymptomatic viral shedding, as well as recurrences. Controlling outbreaks only rarely associated with any serious adverse and minimizing discomfort are two goals of antivi- effects. The severity of a first episode of gen- shown no rise in birth defects or other problems in ital herpes can be dramatically minimized by the more than 10 years. Similar safety is reported in use of an initial 10-day course of medication that the newer entries on the market—valacyclovir helps sores to heal faster, reduces swollen glands, (Valtrex) and famciclovir (Famvir). For chronic suppression, Valtrex is sign of an outbreak; this serves to shorten dura- taken once daily. Famciclovir (Famvir) lasts longer genital herpes 55 in the body than acyclovir, and the herpes patient should be reported to the registry (800-722-9292, takes only twice-daily doses. Oral acyclovir may be taken by a woman who Recurrences has her first episode of genital herpes during preg- It has been seen that people having six or more nancy. Basically, though, the routine use of acy- episodes of herpes a year can reduce the rate of clovir during the pregnancy of a woman with recurrences by 75 percent by availing themselves recurrent infections is not recommended. The extent to disease; and 3 percent for those who have asymp- which this kind of therapy reduces the likelihood tomatic shedding. Abnormal strains seem more likely Understanding the circuitous route that herpes to flourish in these individuals. By the same token, often takes is key to coming to grips with having a no increase in drug-resistant strains of herpes in the disease for which there is no cure. In per- For episodic recurrent infection: sonal relationships, having herpes can feel like having leprosy, and, unfortunately, once it is con- Acyclovir: 400 mg orally three times a day for five tracted, there is little one can do other than try to days, or suppress the symptoms and frequency of bouts Acyclovir: 200 mg orally five times a day for five and take an honest approach with prospective days, or sexual partners. Famciclovir: 125 mg orally twice a day for five Decreased sense of self-worth is a huge problem days, or with herpes, in that many people, after recovering Valacyclovir: 500 mg orally twice a day for three from the initial feeling of betrayal and shock when days they realize they have contracted the disease, move into a state of malaise and inaction. During this Regimens for daily suppressive therapy: time, a redefinition of self can take place, as the individual assigns herself or himself the stigma of Acyclovir: 400 mg orally twice a day, or being “undesirable. In patients who experi- destructive thoughts, as the herpes sufferer experi- ence very severe bouts of herpes or complications ences relationship rebuffs over months and years that make hospitalization necessary (hepatitis, after the disease is contracted. The To combat the feeling of helplessness that often available creams are penciclovir (Denavir) and acy- accompanies this disease, the person with herpes clovir cream. Some have a supportive with infused oxygen to kill the herpesvirus because confidante who helps soothe them during bluesy viruses cannot live in an elevated-oxygen environ- periods; others are comforted by fellow sufferers in ment. In many people point out that episodic antiviral therapy can help to with herpes, the fear of rejection as a result of dis- shorten the duration of lesions and that suppressive closure of herpes is mixed with chagrin and anx- antiviral therapy can help prevent recurrent out- iety. At the same time, herpes sufferers learn, breaks of herpes or render them less frequent and sometimes the hard way, that establishment of an less severe. The first year after initial infection is intimate and satisfying relationship must be based marked by the most frequent outbreaks of herpes. Of course, no In succeeding years, most people experience fewer one should feel compelled to reveal personal outbreaks. However, some people have outbreaks health issues to someone with whom he or she is that are frequent and severe for many years. It is important to remember that those rejections Self-Care that follow on the heels of disclosure of herpes Attention to peace of mind is important for those status should be chalked up as “screening,” in dealing with the lifelong stress generated by having that partners who showed little promise for a herpes. Only those who have herpes can fully mutually beneficial, loving long-term relationship understand the burden of dealing with recurrences are eliminated. There usually are ongoing con- measures can help patients cope successfully with cern and worry about transmitting the disease to a this disease. Those who have distress and no confi- partner and about the necessity to have no sexual dante should be encouraged to seek help via hot- activity during active periods of the sores. Because this disease has asympto- matic shedding, it is extremely important for the • Keep the infected area clean and dry to prevent infected person to understand that sexual trans- development of secondary infections. During wash your hands after you do have contact with counseling, a doctor is likely to caution that it is the sores. Consistent use of condoms during sexual first have symptoms until complete healing has activity with new or uninfected partners should occurred. This can be defined as the time when be a rule of thumb for those with genital herpes. Periods of latency and activity vary with the Another key fact that should be shared in coun- individual, but it remains unclear what causes seling is the risk of neonatal infection. Some research suggests that women are reluctant to disclose that they have her- friction to the genitals can trigger herpes. Stress, pes when their doctors ask for their gynecologic fatigue, sunlight exposure, and menstruation are history, and it is very important that the doctor who also cited as causes. Condoms give some pro- Research tection, but their overall efficacy in curbing Areas of investigation are focusing on causes of transmission rates is dubious. It is rare (but possible) for genital warts to be transmitted by fomites (any nonliving genital secretion In respect to sexually trans- material such as surgical gloves) and by infected mitted diseases, genital fluids and secretions are mothers to newborns. Left untreated, these can regress, remain genital ulcer Superficial skin ulcerations in the the same, or get larger. It is but this disease usually causes a silent infection, believed that another 60 percent in the same age free of visible symptoms. Genital warts are more than 100 known types, varying in affinity for highly contagious. A reluctance to accept the occur are on the external genitalia or perianal area, inevitable makes some patients refuse treatment, and warts can be seen in the vagina, on the cervix, as if denying that they have genital warts will and inside the urethra and anus. They can occur on Transmission the cervix, vagina, vulva, urethra, perianal area, or Skin-to-skin contact with productive lesions that intraanal region. Natural adults; little is known about the mechanics of inoc- history is unknown, and latent infection probably ulation; two-thirds of partners have disease after accounts for recurrences of infection. In rare instances, genital warts develop in the infection remains latent or subclinical. Genital warts can appear in clusters; they can Genital warts that are untreated may regress, be tiny or spread into large masses. Also, a woman genital warts from fomites or from perinatal or dig- should be diligent about having regular Pap ital transmission (via a person’s fingers or hand). Condyloma acuminata in cauliflower shapes, Complications usually on moist surfaces In some rare cases, some infants born to women 2. Papular warts that are dome-shaped, flesh-col- with genital warts have had throat warts (laryngeal ored, smaller than 4 mm, and appear on kera- papillomatosis). They can be life-threatening and tinized skin thus require frequent laser surgery in an effort to 3. Flat-topped papules that are macular or slightly with vulvar cancer, anal cancer, and cancer of the raised and are seen on moist partially kera- penis. The colposcope is used tion of multiple cervical treatments has potential for detecting cervical and vaginal warts. The results of a Pap smear— from the doctor as he or she needs to alleviate anx- the microscopic examination of cells scraped from iety. Depending on the degree eradication of infection, prevention of all seque- of abnormality of the Pap smear result, the patient lae, and elimination of the possibility of transmis- either needs a repeat Pap smear in several months sion to others or of local spread. The treatment or proceeds straight to another test, called a col- can, however, remove visible warts and eliminate poscopy. In colposcopy, a physician is essentially symptoms such as irritation, bleeding, and pruri- looking through an instrument that magnifies the tus. He or she can apply lessened serves to reduce the likelihood of trans- 62 genital warts mission to sex partners and to other parts of the Intraepithelial lesions that are moderate- to body. Cryotherapy has podophyllum for condyloma acuminata, a treat- the disadvantage of a greater probability of recur- ment he supposedly learned from local Native rent disease than that of the others. Treatment was effective but had the downsides: it can increase future risk of second- downsides of toxicity on absorption and high trimester abortion, preterm labor, and low birth recurrence rate. Also used were Many doctors prefer to remove genital warts interferon and 5-fluorouracil, now in disfavor with cryosurgery (freezing), electrocautery (burn- because of their side effects and cost. Large warts that do not The 1990s saw a rapid expansion of under- respond to treatment may require surgery. The drug is simpler-to-use version of podofilox solution, and expensive and has not been proved to affect rate of imiquimod (Aldara) 5 percent cream; both of these recurrence; plus, it has the disadvantage of consid- topical medications are for external genital and erable discomfort for the patient, who must endure perianal warts only. Most treatments prescribed one therapy for home use and one that result in wart-free periods, and some eliminate the doctor administers. Since physicians have seen its, and one treatment that was commonly used that most low-grade cervical intraepithelial lesions in the past—podophyllin resin—appears to be regress spontaneously, doctors no longer treat cer- ineffective. A conservative approach has been • There is a lack of studies in pediatric populations adopted by U. However, if the infection persists • Wart size and number, anatomic location, circum- through several positive Pap smear results, treat- cision status in men, and epithelial presentation ment will probably be required. There are unproven benefits to the female partner of successful treatment and no One report concludes that the most cost-effec- proven benefits to the male partner or future part- tive therapy option is to start patients on ners as far as infectivity. Some treatments cannot achieves the highest overall sustained clearance be used because they carry risk for the fetus. Treatment has labeled imiquimod a Pregnancy Category B choice should be patient-guided; the health care drug, it may be an option for use during pregnancy provider should not overtreat; and no treatment if the patient is properly briefed. Treatment selection should are cautioned not to use podophyllin or podofilox be determined by considering wart size, number, because both are absorbed by the skin and may sites, and morphological features; patient prefer- cause birth defects. Possible complications of ablation are can make the vagina less elastic and cause delivery cosmetic alterations, such as scarring and hypo- or obstruction. In rare cases, a cesarean section is refrain from sexual contact until these are treated. For life, such patients need to have yearly the idea of rejecting treatment and maintaining pelvic exams with Pap smears. Some patients who have genital warts experience sleep problems, irritability, crying Prevention jags, anger outbursts, weight swings, and rela- Many researchers and health care professionals see tionship difficulties. One study found that enter- by condoms because the disease is spread during taining adolescents with music videos reduced foreplay and other forms of sexual contact. A man can there is actually no way to pinpoint when and get genital warts when vaginal secretions with where a person got the infection. Risk of serious consequences to the disease is spread by transmission from fomites the male partner, other than warts, is low. In fact, it is Two patient-applied treatments are handled as fol- considered even stronger than the tobacco–lung lows. The packet is discarded and hands are Admittedly, there are probably other factors at washed again. Having an oncogenic type When using podofilox gel, a small amount (half makes the woman have a greater chance of per- the size of a pea) is squeezed onto a fingertip and sistent infection that leads to viral integration and dabbed onto warts or areas the doctor has said is a more significant predictor of neoplastic pro- should be treated. Studies have noted, incidentally, that among women in whom cervical nal warts or other body areas. One would prevent that is why women usually are diagnosed with cer- infection or disease, and the other would be used vical cancer in midlife or later. Some strides have type assay are not always accurate in prognosti- been made, but much work remains. The event, response via a viral load assay the most accurate which 700 experts from 52 countries attended, test. The genotype assay helps to guide initial drug called on corporations, educational institutions, selection in salvage regimens. Cause The cause of gonorrhea is the bacterium Neisseria gingivostomatitis Primary gingivostomatitis, gonorrhoeae, which grows and multiplies in moist, which results from herpes simplex virus infec- warm areas of the body, including the reproduc- gonorrhea 67 tive tract, oral cavity, and rectum.

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