What if I put it up my nose?

By Michael J. McGuire

Water utilities are required to provide drinking water that is safe for their customers to drink. But what about other uses of municipal water? Is a water utility responsible for ensuring the safety of water that is introduced into the nose?

Over the past couple of days, news stories have been covering the death of a 4-year old boy in St. Bernard Parish, Louisiana, who contracted Primary Amoebic Meningoencephalitis (PAM) most likely by coming in contact with an amoeba called Naegleria fowleri. Officials from the Center for Disease Control and Prevention stated that it is likely he was exposed while playing on a Slip ‘N Slide in his backyard where tap water was used as part of the fun.

It is only possible to contract PAM by taking water contaminated with Naegleria fowleri directly into the nose. Once the microbes are in the nasal area they can migrate to the olfactory bulbs and move directly into the brain. The disease is almost 100 percent fatal but, thankfully, its occurrence is rare.

What caught my attention was the title of the news item on the NBC News website:  “Deadly brain amoeba infects US tap water for the first time.” I knew that was not true. I was a consultant to a water utility in the Phoenix, Arizona, area in 2004 and 2005 that was peripherally involved in (and not responsible for) a tragic episode involving the amoeba in 2002.

On October 12 and 13, 2002, two 5-year old boys died of PAM within four hours of each other at two different Phoenix area hospitals. The boys and their families did not know each other. They had nothing in common—except their water supply from the Rose Valley Water Company. Both had been playing in different swimming pools filled with water from that small, private water utility. Also, in common was the fact that the water was not chlorinated…at all. Samples taken later from reservoirs and the distribution system of the water company were positive for Naegleria fowleri (the so-called “brain-eating amoeba”).

The investigation of this water utility uncovered some very disturbing information, but the most disturbing fact was that the water supply was not chlorinated. News reports of the recent case in St. Bernard Parish have stated that the water supply was poorly disinfected. Naegleria fowleri are known to infest and grow in warm water. Most of the deaths in the U.S., Australia and other countries resulted from people (mostly children) jumping into fresh water ponds or rivers in hot climates. But should children be cautioned against doing a cannonball in the local swimming pool that is filled with municipal water? The CDC thinks so. On the website explaining the problem with the amoeba is the statement: “Do not allow water to go up your nose or sniff water into your nose when bathing, showering, washing your face, or swimming in small hard plastic/blow up pools.”

Really? Let’s see if there is another possible solution to this problem since we are not going to keep water out of a kid’s nose. I know. PROPERLY DISINFECT THE TAP WATER AND KEEP IT DISINFECTED! Naegleria fowleri can be easily killed by chlorine, ozone, and UV light. A study at Arizona State University found that it was possible to find the amoeba in biofilms in distribution systems. Ok, that makes it a little more challenging, but an effective secondary disinfectant residual will kill any of the amoeba that escape from the biofilm into the bulk water phase. Control of biofilms by limiting nutrients and carbons sources that foster their growth is another good operational procedure.

So, does a water utility have to worry about a kid putting water up his nose? There is no question about it. They better be worried about this happening. A utility that operates in the U.S. Sunbelt that does not disinfect the water that it sends out to the public is risking another one of these heartbreaking tragedies.

References

Brown, A. et al. “Naegleria fowleri: Highly Fatal, But Rare.” presented to the 2012 Gatekeeper Regulatory Roundup Conference, Scottsdale, Arizona, April 3, 2012, http://www.epaz.org/userfiles/14-Naegleria%20Fowleri-%20A%20Brown-rev.pdf

CDC, “Naegleria fowleri and Public Drinking Water Systems,” http://www.cdc.gov/parasites/naegleria/public-water-systems.html  Accessed September 17, 2013.

Fox, M. “Deadly Brain Amoeba Infects US Tap Water for the First Time.” NBC News, http://www.nbcnews.com/health/deadly-brain-amoeba-infects-first-us-drinking-water-system-8C11172643 Accessed September 17, 2013.

Wikipedia, “Naegleria fowleri.” https://en.wikipedia.org/wiki/Naegleria_fowleri, Accessed September 17, 2013.

UPDATE!!! July 28, 2015

DHH Confirms Naegleria Fowleri Ameba in Ascension Consolidated Utility District 1

Drinking water is safe to consume, but State urges public to take precautions

Baton Rouge, La. – Tuesday, the Louisiana Department of Health and Hospitals (DHH) confirmed the presence of the Naegleria fowleri ameba in the Ascension Consolidated Utility District 1 at the site 9295 Brou Road. The water system, which serves approximately 1,800 residents in a small community north of Donaldsonville in Ascension Parish, was tested by DHH as part of the State’s new public drinking water surveillance program. DHH notified the water system and local officials Tuesday afternoon. The Department asked the water system to conduct a 60-day chlorine burn to ensure that any remaining ameba in the system are eliminated. Parish officials today confirmed that the system would conduct the burn out of an abundance of caution.

The water system was not in compliance with the requirements for chloramine disinfectant levels set forth by the 2013 by emergency rule and additional requirements in 2014 by the Louisiana Legislature at the location where the sample tested positive for the ameba. Three other sites on the system tested negative for the ameba, but did meet the requirement for disinfectant.

Tap water in from the Ascension Consolidated Utility District 1 is safe for residents to drink, but the Department urges residents to avoid getting water in their noses. Naegleria fowleri is an ameba that occurs naturally in freshwater.

As Naegleria fowleri infections are extremely rare, testing for this ameba in public drinking water is still relatively new and evolving. Fewer than 10 deaths in the United States have been traced back to the ameba, with three occurring in Louisiana over the last several years.

DHH conducts sampling of public drinking water systems for Naegleria fowleri each summer when temperatures rise. So far, DHH has tested 12 other systems for the ameba. One positive result was identified on July 22 in St. Bernard Parish. St. Bernard Parish is currently conducting a chlorine burn throughout their water system to eliminate any remaining ameba.

Naegleria fowleri causes a disease called primary amebic meningoencephalitis (PAM), which is a brain infection that leads to the destruction of brain tissue. In its early stages, symptoms of PAM may be similar to bacterial meningitis.

DHH Safe Drinking Water Program staff sampled four sites along the Ascension Consolidated Utility District 1. One of the four sites tested positive for the ameba. One positive test was located at 9295 Brou Road. Chlorine levels at the site of the positive sample were below the 0.5 mg/l requirement.

The Department requested that the water system conduct a 60-day free chlorine burn in the water system. The chlorine burn will help reduce biofilm, or organic buildup, throughout the water system and will kill the ameba. The parish has agreed to conduct this precautionary measure.

Precautionary Measures for Families

According to the CDC, every resident can take simple steps to help reduce their risk of Naegleria fowleri infection. Individuals should focus on limiting the amount of water going up their nose. Preventative measures recommended by the CDC include the following:

• DO NOT allow water to go up your nose or sniff water into your nose when bathing, showering, washing your face, or swimming in small hard plastic/blow-up pools.
• DO NOT jump into or put your head under bathing water (bathtubs, small hard plastic/blow-up pools); walk or lower yourself in.
• DO NOT allow children to play unsupervised with hoses or sprinklers, as they may accidentally squirt water up their nose. Avoid slip-n-slides or other activities where it is difficult to prevent water going up the nose.
• DO run bath and shower taps and hoses for five minutes before use to flush out the pipes. This is most important the first time you use the tap after the water utility raises the disinfectant level.
• DO keep small hard plastic/blow-up pools clean by emptying, scrubbing and allowing them to dry after each use.
• DO use only boiled and cooled, distilled or sterile water for making sinus rinse solutions for neti pots or performing ritual ablutions.
• DO keep your swimming pool adequately disinfected before and during use. Adequate disinfection means:
  • Pools: free chlorine at 1 to 3 parts per million (ppm) and pH 7.2 to 7.8, and
  • Hot tubs/spas: free chlorine 2 to 4 parts per million (ppm) or free bromine 4 to 6 ppm and pH 7.2 to 7.8.
• If you need to top off the water in your swimming pool with tap water, place the hose directly into the skimmer box and ensure that the filter is running. Do not top off the pool by placing the hose in the body of the pool.

Residents should continue these precautions until testing no longer confirms the presence of the ameba in the water system. Residents will be made aware when that occurs. For further information on preventative measures, please visit the CDC website here: http://www.cdc.gov/parasites/naegleria/prevention.html.