NEHA November 2024 Journal of Environmental Health

The November 2024 issue of the Journal of Environmental Health (Volume 87, Number 4), published by the National Environmental Health Association.

JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional Volume 87, No. 4 November 2024

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JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional Volume 87, No. 4 November 2024

ADVANCEMENT OF THE SCIENCE Comparison of the Extended-Spectrum Beta-Lactamase (ESBL) E. coli Compartment Bag Test Method to the World Health Organization Tricycle Protocol in North Carolina Surface Waters.................................................................................8

ABOUT THE COVER

On July 15–18, 2024, the National Environmental Health Associa- tion (NEHA) held its 87th Annual Educational Conference (AEC)

An Overview of Major Occupational Lung Diseases.................................................................14

Qualitative Refinement of a Survey About Tickborne Disease..................................................24

& Exhibition in Pittsburgh, Pennsylvania. The 2024 AEC brought together nearly 1,300 in-person and virtual attend- ees—both nationally and globally—to explore new horizons in our profession. The theme of the conference was, “New Horizons: Building Bridges to Shape the Environmental Health Future.” We feature a special wrap-up of the 2024 AEC in this issue, highlighting our fea- tured speakers, educational sessions, preconfer- ence offerings, social events, exhibition, and award and scholarship winners. See page 46. Graphics designed by Seth Arends, Seenior Graphic Designer, NEHA. using the city builder pack from atipo illustrations.

ADVANCEMENT OF THE PRACTICE

Building Capacity: Building Capacity Through On-Demand Learning ......................................... 30

Direct From ATSDR: Computational Modeling Approaches Applied to Public and Environmental Health ........................................................................................................... 32 Direct From CDC/Environmental Health Services: Challenge Your Assumptions for C learer Communication ........................................................................................................ 36

ADVANCEMENT OF THE PRACTITIONER

Environmental Health Calendar................................................................................................40

Spotlight on NEH Resources: Supporting Students ..................................................................... 42

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CDP, Inc.:................................................................7 EHLR Certificate Program:...................................22 EMSL Analytical, Inc.:..........................................71 Hedgerow Software.................................................2 HS GovTech..........................................................72 Kent State University, College of Public Health....39 NEHA Awards.................................................23, 41 NEHA Credentials................................................12 NEHA Endowment Foundation Donors..............65 NEHA Job Board...................................................40 NEHA Membership................................................4 NEHA REHS/RS Study Guide...............................38 NEHA Student Research Competition..................43 NEHA/AAS Scholarship........................................43 NEHA/AAS Scholarship Fund Donors....................5 NSF....................................................................... 13

YOUR ASSOCIATION

President’s Message: Emerging Threats to Indoor Air Quality .................................................................. 6

Special Listing............................................................................................................................44

NEHA 2024 AEC Wrap-Up.......................................................................................................46

A Tribute to Our 25-Year and Beyond Members........................................................................62

U.S. Postal Service Statement of Ownership...............................................................................66

NEHA 2025 AEC.......................................................................................................................67

NEHA News...............................................................................................................................68

November 2024 • Journal of Environmental Health

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in the next Journal of Environmental Health don’t miss  Beyond the Slimy Biolms: The Emergence of Dry Surface Biolms as a Concern for Infection Transmission in Public Settings  Solid Waste Management in the Republic of Benin: The Case of the Five Municipalities of the Grand Nokoué  Warmer Air Disrupts Downward Trend in Ozone Concentrations in North-Central Texas

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Volume 87 • Number 4

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November 2024 • Journal of Environmental Health

YOUR ASSOCIATION

Open Access

 PRESIDENT’S MESSAGE

Emerging Threats to Indoor Air Quality

CDR Anna Khan, MA, REHS/RS

W hen preparing for cooler weather and the November and Decem- ber holiday seasons with friends and family, we often spend more time inside homes, offices, restaurants, schools, and places of worship. This fact makes indoor air quality a concern. During the COVID-19 pandemic, some of us did not leave our homes for 2 to 4 years and schools and o ce spaces sat unoccupied. People are returning to work in person to a greater degree and of- fice spaces are being used again. O ce spaces are not, however, used as often as they once were. According to a Pew Research Center study, approximate one third (35%) of workers with jobs that can be done remotely are working from home full time (Parker, 2023). This occurrence leads us into a new situation with buildings sitting vacant and the need for repurposing the space. A report from The White House (2023) states that o ce vacancies reached a 30-year high of 18.2% in the second quarter of 2023. Amid a housing crisis where the average renter spends at least 30% of their income on rent, the process of converting commercial property to residential housing is becoming a common priority. Anytime an important decision such as this one is made, however, I am not sure if all the subject matter experts are at the table to discuss the issues. For instance, indoor air quality became a hot topic during the pan- demic and remains a prominent issue, par- ticularly if buildings originally designed for commercial or industrial purposes are being repurposed into residential spaces. These conversions often bring unique challenges, as the original ventilation and air filtration

tial amounts of smoke that is filled with fine particulate matter (PM 2.5 ), carbon monoxide, and other pollutants. These particles can eas- ily penetrate building envelopes through gaps around windows, doors, and ventilation sys- tems, leading to poor indoor air quality even when the fire is miles away. Prolonged exposure to wildfire smoke can aggravate respiratory conditions, cause eye irri- tation, and contribute to cardiovascular issues. The respiratory risks are worse for select popu- lations (e.g., infants, older adults, and people with certain conditions). To mitigate these harmful eects, it is essential to use air puri- fiers with HEPA filters, ensure proper sealing of indoor spaces, and monitor air quality levels. Addressing the infiltration of wildfire smoke helps protect occupant health and maintains a safe and comfortable living environment dur- ing fire seasons and year-round in some areas where there is no longer a set fire season. While several federal programs are dedi- cated to supporting the e cient conver- sion of commercial spaces to residential spaces, The White House is committed to advancing the Housing Supply and Action Plan that will allocate $3 billion annually to nationally support several components of the conversion process. With so much focus and attention from national policy- makers and political leaders, it is critical to have environmental health professionals at the table with community leaders and poli- cymakers to make sure that environmental public health issues are being addressed to protect communities from public health the- ats as the planning and repurposing of these spaces are being strategically developed.

By developing a clear policy statement on indoor air quality, NEHA will establish itself as the gold standard in environmental public health issues.

systems might not meet the needs of a liv- ing environment. Issues such as inadequate air circulation, the presence of construction materials that o-gas volatile organic com- pounds (VOCs), and the accumulation of dust and pollutants can compromise air qual- ity in these newly converted spaces. As more people move into such buildings, the impor- tance of addressing these air quality concerns becomes increasingly evident. Ensuring that these adapted spaces have proper ventilation, eective filtration, and monitoring systems is crucial for maintaining healthy and comfort- able living conditions. Another air quality issue that continues to be a bigger problem with climate change is the ability to filter smoke that originates from local wildland fires. Smoke significantly degrades indoor air quality and poses serious health risks. Wildfires can produce substan-

Volume 87 • Number 4

References Parker, K. (2023, March 30). About a third of U.S. workers who can work from home now do so all the time . Pew Research Center. https://www.pewresearch.org/short-reads/ 2023/03/30/about-a-third-of-us-workers- who-can-work-from-home-do-so-all- the-time/ The White House. (2023, October 27). Com- mercial-to-residential conversion: Addressing o c e va c a n c i e s . https://www.whitehouse. gov/cea/written-materials/2023/10/27/ commercial-to-residential-conversion- addressing-oce-vacancies/

Environmental health professionals are uniquely trained and experienced to leverage their scientific and applied expertise to ensure that these new living spaces are safe to nur- ture families and promote their well-being. Over the next few months, the board of the National Environmental Health Association (NEHA) will work on a policy statement about indoor air quality because it is our responsi- bility to speak up about these concerns and protect our communities. Similar to what we have developed for climate change, food safety, and other crucial issues, we plan to share this policy statement with state, local, and federal policymakers, including both the executive and legislative branches, as well as relevant environmental and public health boards.

By developing a clear policy statement on indoor air quality, NEHA will establish itself as the gold standard in environmental public health issues. Further, we can garner a seat at the table for discussions regard- ing indoor air quality. These discussions will include the emerging issues associated with repurposing commercial spaces to resi- dential ones and the continued struggles of addressing increasing incidences of wildfire smoke in our communities.

akhan@neha.org

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November 2024 • Journal of Environmental Health

ADVANCEMENT OF THE SCIENCE

Open Access

Abstract E. coli and total coliforms are the most widely used indicator organisms for microbial monitoring of drinking water and recreational freshwater. In many remote and low-resource settings, however, conventional laboratory methods for quantifying these indicators are challenging or infeasible to perform due to limited access to laboratory facilities. The availability of rapid, low-cost methods for quantifying indicator organisms in freshwater samples without the need for laboratory facilities is crucial to facilitate the rapid and robust monitoring of microbial water quality in these types of settings. The global misuse and abuse of antimicrobials have contributed to the rise of antimicrobial resistance. Thus, simple culture methods are needed to detect indicators of such bacteria in freshwaters. In 2021, the World Health Organization released the Tricycle protocol to address this issue by providing guidance for culture- based detection of extended-spectrum beta-lactamase (ESBL)-producing E. coli in environmental samples. Our research goal was to compare the 100-ml sample volume ESBL E. coli quantal and enumerative commercial tests against the more complex Tricycle protocol to detect and quantify ESBL E. coli in surface waters. Both commercial tests gave results comparable with the results obtained using the Tricycle protocol, and the quantal and enumerative commercial tests were easier and faster to perform than the Tricycle protocol. Keywords: E. coli , antibiotic resistance, extended-spectrum beta-lactamase, ESBL, field test methods, surface water Comparison of the Extended-Spectrum Beta-Lactamase (ESBL) E. coli Compartment Bag Test Method to the World Health Organization Tricycle Protocol in North Carolina Surface Waters

Cindy Fan Department of Public Health, College of Pharmacy & Health Sciences, Campbell University Emily S. Bailey, PhD Department of Public Health, College of Pharmacy & Health Sciences, Campbell University

table, low-cost, semiquantitative procedure for quantifying E. coli in drinking water and surface water samples using ambient tem- perature incubation (Gronewold et al., 2017; Stauber et al., 2014; Wang et al., 2017). A newer version of this simple culture test for E. coli in a plastic bag uses a gel medium to detect and quantify E. coli and total coliforms as colonies. Once mixed with a water sample, the gel medium hardens in a short time and E. coli colonies then develop and are counted after an overnight incubation. The increasing global misuse and abuse of antimicrobials in clinical, veterinary, and agricultural settings have contributed to the rise of antimicrobial resistance, which is a stated One Health global concern (World Health Organization [WHO], 2016). This rise created an urgent need to develop and use harmonized culture methods to detect and quantify an E. coli indicator of antimi- crobial resistance for all settings. In 2021, the World Health Organization (WHO, 2021) released the Tricycle protocol to address this issue by providing guidance on the culture- based detection of extended-spectrum beta- lactamase (ESBL) E. coli in environmental, clinical, and animal agriculture samples. To better address the need to detect and quantify ESBL E. coli in environmental waters, new versions of these simple commercial tests included the same beta-lactam antibiotic that is used in the Tricycle protocol. The goal of our research was to compare the two commercial tests—the 100-mL sam- ple volume ESBL E. coli MPN (most prob- able number) CBT test and the GEL ESBL CFU test—to gauge the results against the WHO Tricycle protocol. To our knowledge, this study is the first to compare these meth- ods using field samples of environmental surface waters.

Introduction E. coli and total coliforms are the most widely used indicator organisms for microbial moni- toring of drinking water and recreational freshwater. In many remote and low-resource settings, however, conventional laboratory methods for quantifying these bacterial indi- cators are challenging or infeasible to per- form due to the absence of timely access to laboratory facilities within allowed holding times and temperatures (Organisation for

Economic Co-operation and Development, 2019; Sargeant et al., 2019). The availabil- ity of rapid, low-cost commercial methods for quantifying these indicator organisms in freshwater samples without the need for laboratory facilities provides rapid and con- venient monitoring of microbial water quality in such settings. The compartment bag test (CBT) is one such method that has been validated in the field in a variety of settings as a simple, por-

Volume 87 • Number 4

Methods

GEL bag test, the limit is estimated to be 1.0 CFU/100 ml. For each method, a subset of presumptive ESBL-positive E. coli samples was isolated for further characterization. Overall, one to five presumptive ESBL E. coli colonies were selected from each membrane filtration plate, ESBL CBT, or GEL ESBL E. coli bag. The col- onies were re-streaked for isolation on TBX medium with 4 mg/L CTX as an initial ESBL E. coli confirmation step. Colonies were picked at random from these plates using a sterile loop. The exte- rior of positive compartments of CBTs were swabbed with 70% ethanol. Next, the com- partments were pierced with a sterile syringe and needle, and a drop of medium was spot- ted onto TBX plates with CTX and streaked as described to obtain individual colonies after incubation. For GEL ESBL E. coli positives, the exterior of the GEL bag was swabbed with 70% ethanol, and a large-gauge sterile syringe was used to pierce the GEL medium of the bag. In some instances, it was necessary to use the sterile syringe in combination with a sterile isolation needle to spread the positive colony from the GEL bag. Colonies isolated from re-streaked TBX plates were picked with a sterile loop, cul- tured initially on tryptic soy agar (TSA), cultured again overnight in tryptic soy broth (TSB), diluted 1:1 with sterile glycerol, and stored at -80 °C in sterile 2-ml cryovials. Stored isolates were thawed and further char- acterized by biochemical testing, specifically the indole test, according to the manufac- turer’s instructions. Isolates were further con- firmed as ESBL by Kirby–Bauer susceptibility testing using the criteria defined in the Tri- cycle protocol (WHO, 2021) for CTX, ceftazi- dime (CAZ), CTX + clavulanic acid (CLA), and CAZ + CLA as paper discs. The distributions of presumptive and con- firmed ESBL E. coli CFU and MPN concen- trations were characterized for each method (membrane filtration, ESBL CBT, and GEL ESBL). E. coli concentrations were subjected to Shapiro–Wilk normality tests, and the geo- metric mean, arithmetic standard deviation, and range (minimum and maximum) were calculated. A 0.5 minimum limit of detec- tion was used to reduce bias for nondetects, such that a nondetect for a 100-ml undiluted surface water sample would be calculated as 0.5/100 ml—rather than 0/100 ml—to mini-

mize bias and enable log 10 -transformation of count data where needed. The confirmed proportion of ESBL E. coli was calculated as the ratio of confirmed ESBL E. coli isolates to total isolates tested, adjusted for the number of total isolates collected from each sample type. Dierences in log 10 -trans- formed concentrations between each test method were evaluated using nonparamet- ric methods. All analyses were conducted in GraphPad Prism version 10. Results Concentrations of ESBL E. coli in surface water samples were relatively low (<100 CFU or MPN per 100 ml) throughout the study period and the total percentage of presump- tively resistant E. coli to nonresistant E. coli varied between 1.5% and 15.2%. Table 1 pres- ents the occurrence of presumptively positive ESBL E. coli by assay method, and Figure 1 displays a box and whisker plot of the pre- sumptively positive concentrations. To further evaluate the three methods used to detect ESBL E. coli , a Friedman test was used because a normal distribution did not adequately represent this data set. At an α level of .05, there was no statistically significant dif- ference between the median detected concen- tration of the Tricycle protocol membrane fil- tration method compared with the ESBL CBT ( p = .57), the membrane filtration method compared with the GEL ESBL method ( p > .99), and the ESBL CBT method compared with the GEL ESBL method ( p > .99). Isolate Analysis for ESBL E. coli Analysis was performed on 306 presump- tively positive ESBL E. coli isolates detected in the 100 surface water samples (Table 2). There were 117 ESBL E. coli isolates ana- lyzed from the membrane filtration method, as well as 91 and 98 isolates analyzed from the ESBL CBT and GEL ESBL methods, respectively. The isolates were initially confirmed by streak plating on TBX agar medium containing CTX. Of the samples first identified as presumptive ESBL E. coli , 92.8% were confirmed on the CTX agar plates. By method, 94.0%, 96.7%, and 87.8% of isolates were confirmed using this tech- nique from the membrane filtration, ESBL CBT, and GEL ESBL methods, respectively. Next, isolates were confirmed as E. coli using an indole test. Overall, 85.6% of the

Sample Collection A total of 100 samples were collected from May–September 2023 from a variety of sur- face water sources in central North Carolina. Sample sites included two reservoirs, two lakes (Sunset and Jordan), and three rivers (Cape Fear, Neuse, and Eno). Grab samples of surface waters were collected using sterile polypropylene bottles. Samples were trans- ported and stored on ice at 4 ° C and analyzed within 24–48 hr after collection. Sample Processing and Data Analysis To address anticipated low concentrations of ESBL E. coli , surface water samples were mixed well and analyzed as 100-ml volumes without dilution by all three test methods. Membrane filtration was performed by fil- tering samples through 0.45-µm cellulose nitrate filters followed by incubation at 44 ° C for 24 hr on 100-mm diameter Tryptone Bile X-glucuronide (TBX) agar plates with or without 4 mg/L added cefotaxime (CTX) per the Tricycle protocol (WHO, 2021). We tested duplicate plates for each water sample ( n = 200). Parallel 100-ml samples were analyzed using the ESBL CBT for MPN concentra- tions/100 ml and the GEL ESBL E. coli colony test for CFU concentrations/100 ml. All CBT and GEL samples were incubated at 35 °C for 24 hr. If a CBT compartment exhibited a blue-green color after incubation or if a GEL bag had a blue-green colony, that compart- ment or colony was counted as positive. Positive and negative control plates (for membrane filtration method) and bags (for CBT and GEL methods) were tested one time per week. A positive control ESBL E. coli , a non-ESBL-negative control bacteria, and a negative dilution control (phosphate buered saline [PBS]) were used for each set of experi- ments. Additionally, at the beginning of our experiment, all positive control bacteria were compared in a clean matrix (PBS) using each of the methods (Appling et al., 2023) to deter- mine if the methods were comparable to no outside water interactions. The limit of detec- tion for each method is described in the manu- facturer’s instructions (www.aquagenx.com/). For the ESBL CBT method, the limit is estimated to be 0.0 MPN, with an upper 95% confidence limit of 2.87 MPN/100 ml. For the

November 2024 • Journal of Environmental Health

ADVANCEMENT OF THE SCIENCE

TABLE 1

FIGURE 1

Occurrence of Presumptive Extended-Spectrum Beta-Lactamase (ESBL) E. coli by Assay Method

Box and Whisker Plot of Presumptive Positive Extended-Spectrum Beta- Lactamase (ESBL) E. coli Concentrations

Metric

Measurement

Membrane Filtration (CFU)

ESBL CBT (MPN)

GEL ESBL (CFU)

Geometric mean

CFU or MPN/100 ml

1.12 0.69

1.00 0.64

1.05 0.69

Log 10 CFU or MPN/100 ml

Nondetect Minimum

62%

71%

70%

Log 10 CFU or MPN/100 ml Log 10 CFU or MPN/100 ml

-0.30

-0.40

-0.30

2.03

1.87

1.69

Maximum

Note. CBT = compartment bag test; CFU = colony forming unit; MPN = most probable number.

isolates were confirmed using this method. Lastly, isolates were evaluated for ESBL posi- tivity using the Tricycle protocol confirma- tion criteria. Using this technique, 64.4% of the isolates were found to be ESBL-resistant (scored as ESBL-positive). By method, 55.6% of the membrane filtration isolates were resis- tant, 76.9% of the ESBL CBT isolates were resistant, and 60.2% of the GEL ESBL isolates were resistant. Discussion The results of this study indicate that the three methods detect similar concentrations of ESBL E. coli in surface water. Based on a Freidman test analysis, there was no statisti- cally significant difference between any of the methods in detecting median concentrations. This result is similar to other evaluations of the E. coli CBTs (Stauber et al., 2014; Wang et al., 2017) and initial evaluations of the ESBL CBT method (Appling et al., 2023). In the surface water samples collected for our study, there were low concentrations of ESBL E. coli , ranging from nondetect- able amounts to approximately 100 CFU or MPN per 100 ml. The rate of nondetects was between 62% and 71% of each sample set depending on the assay type (Table 1). Other studies conducted on surface waters also showed high numbers of nondetects for ESBL E. coli (Blaak et al., 2014), indicating that input into these waters—including wastewa- ter, surface runoff, and animal waste—might not be consistent throughout the year and

could be dependent on temperature, weather, and other factors. In our confirmation analysis of the ESBL E. coli isolates, each of the three methods resulted in a similar number of positive iso- lates, specifically the membrane filtration method ( n = 117), ESBL CBT ( n = 91), and GEL ESBL ( n = 98). Each isolate was then subjected to a series of confirmation tests including a secondary streak plating on ESBL antibiotic-impregnated TBX agar, an indole test, and then antibiotic resistance testing according to the Tricycle protocol. Each method was able to detect a similar percent- age of positive ESBL-resistant E. coli , adjusted for the number of isolates analyzed. Of the 117 isolates detected from the mem- brane filtration method, 65 (55.6%) were con- firmed by the methods previously described and identified as ESBL-positive E. coli . For the ESBL CBT method, 70 of the 91 initial isolates identified (76.9%) were confirmed as ESBL E. coli. For the GEL ESBL method, 59 of the 98 isolates (60.2%) were confirmed as ESBL E. coli. These resistance percentages are higher than the percentages reported in the initial evaluation of the ESBL CBT (Appling et al., 2023); however, our results are similar to other evaluations of isolates in surface waters in North America (Haberecht et al., 2019). Although not directly considered in the methods comparison presented in our evalu- ation, previous published work has compared CBT to standard laboratory methods, includ- ing the membrane filtration method consid-

-1

MF CBT GEL

ered here (Bain et al., 2012). When factor- ing in the cost of agar and petri dishes, the estimated cost of the standard CBT method is approximately the same amount per sam- ple. The ease of use for the CBT, however, which allows a user to process the sample without the need for an incubator, special- ized pipette, or other laboratory equipment, greatly reduces the cost of this test itself. For limited-resource settings, field tests such as the CBT or GEL method offer an opportunity to test for pathogens that might not be con- sidered within standard monitoring practice due to a lack of available facilities or labora- tory equipment. The three methods we evaluated are com- parable in terms of the detection of ESBL E. coli concentrations and the overall confir- mation of ESBL E. coli isolates. There were several limitations. Specifically, while the ESBL CBT detects MPN concentrations and membrane filtration and GEL ESBL methods detect CFU concentrations, we compared Note. Lines denote median log 10 -transformed concentrations. Boxes denote first and third quartile log 10 concentrations. Whiskers denote 95% confidence limits for log 10 concentration values. Mean values are designated by the dashed line. CBT = ESBL compartment bag test; CFU = colony forming unit; GEL = GEL ESBL; MF = membrane filtration; MPN = most probable number.

Volume 87 • Number 4

were confirmed as ESBL E. coli . For the ESBL CBT method, 76.9% of the presumptively positive isolates were confirmed as ESBL E. coli . Lastly, for the GEL ESBL method, 60.2% of the presumptively positive isolates were confirmed as ESBL E. coli. These field meth- ods likely are suitable for field applications in settings with limited resources or infrastruc- ture, as they gave comparable results to the standard method, which is not easily usable in the field because it requires additional materials and equipment. Continued and widespread monitoring of ESBL E. coli in environmental waters is a useful monitoring and surveillance approach for antimicrobial resistance, and as such is recommended by WHO. Our research sug- gests the need, however, to further adapt and simplify the current Tricycle protocol to more easily and broadly detect ESBL E. coli in envi- ronmental waters by field testing. Acknowledgments: Support for this project was provided by Aquagenx. The funders, however, had no role in the data collection and analy- sis components of this work. We acknowledge Amina Bash, Lauren Burke, and Elina Thomas for their expertise in processing laboratory samples. We thank Dr. Mark D. Sobsey of the University of North Carolina for his helpful review of this manuscript. Corresponding Author: Emily S. Bailey, Assis- tant Professor, Department of Public Health, College of Pharmacy & Health Sciences, Campbell University, 4350 U.S. Highway 421

TABLE 2

Results of Isolate Confirmation Testing by Assay Method

Method

CTX Streak Plating # (%)

Indole Positive # (%)

ESBL Positive # (%)

Membrane filtration ( n = 117)

110 (94.0) 88 (96.7) 86 (87.8) 287 (92.8)

97 (82.9) 83 (91.2) 82 (83.7) 262 (85.6)

65 (55.6) 70 (76.9) 59 (60.2) 197 (64.4)

ESBL CBT ( n = 91) GEL ESBL ( n = 98)

Total ( N = 306)

Note. CBT = compartment bag test; CTX = cefotaxime; ESBL = extended-spectrum beta-lactamase.

the three methods directly for our evalua- tion. This method of direct comparison has been previously evaluated and although con- centrations dier when microorganisms are detected by each method for a variety of rea- sons, when these methods are used on field samples or in field settings, the results appear to be equivalent (Eckner, 1998; Gronewold & Wolpert, 2008). As such, in our evaluation, microbial concentrations based on CFU and MPN units are treated as equivalent, as previ- ously documented by Bailey et al. (2017). The ESBL CBT and GEL ESBL methods are portable and easy to use and would be par- ticularly applicable when used in field condi- tions. For the GEL ESBL method, however, there is a learning curve and the manufac- turer’s instructions are cumbersome to a new user. Therefore, for more consistent results, it could be helpful to provide additional visual aids for the use of this method. These methodological limitations, in addi- tion to the limited number of samples ( n =

100), are important considerations when comparing the various experimental meth- ods. Despite these limitations, the results from our evaluation of 306 presumptive ESBL E. coli isolates examined across the three methods would be comparable with results one would expect with testing using the Tricycle protocol. Additionally, although it was not a direct focus of our evaluation, the quality of the surface water included in our comparison of the three methods is a relevant variable that would be interesting to consider in future comparisons. Conclusion Our evaluation provides quantitative evidence that the three dierent culture methods we compared can detect statistically similar lev- els of ESBL E. coli in surface water samples. We found no statistically significant dier- ence in the three methods for detecting ESBL E. coli. For the membrane filtration method, 55.6% of the presumptively positive isolates

South, Lillington, NC 27546. Email: ebailey@campbell.edu

References

Appling, K.C., Sobsey, M.D., Durso, L.M., & Fisher, M.B. (2023). Environmental monitoring of antimicrobial resistant bacteria in North Carolina water and wastewater using the WHO Tricycle protocol in combination with membrane filtration and compart- ment bag test methods for detecting and quantifying ESBL E. coli . PLOS Water , 2 (9), e0000117. https://doi.org/10.1371/journal. pwat.0000117 Bailey, E.S., Price, M., Casanova, L.M., & Sobsey, M.D. (2017). E. coli CB390: An alternative E. coli host for simultaneous detec- tion of somatic and F+ coliphage viruses in reclaimed and other waters. Journal of Virological Methods , 250 , 25–28. https://doi. org/10.1016/j.jviromet.2017.09.016

Bain, R., Bartram, J., Elliott, M., Matthews, R., McMahan, L., Tung, R., Chuang, P., & Gundry, S. (2012). A summary catalogue of microbial drinking water tests for low and medium resource set- tings. International Journal of Environmental Research and Public Health , 9 (5), 1609–1625. https://doi.org/10.3390/ijerph9051609 Blaak, H., de Kruijf, P., Hamidjaja, R.A., van Hoek, A.H.A.M., de Roda Husman, A.M., & Schets, F.M. (2014). Prevalence and character- istics of ESBL-producing E. coli in Dutch recreational waters influ- enced by wastewater treatment plants. Veterinary Microbiology , 171 (3–4), 448–459. https://doi.org/10.1016/j.vetmic.2014.03.007

continued on page 12

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Eckner, K.F. (1998). Comparison of membrane filtration and mul- tiple-tube fermentation by the Colilert and Enterolert meth- ods for detection of waterborne coliform bacteria, Escherichia coli , and enterococci used in drinking and bathing water qual- ity monitoring in southern Sweden. Applied and Environmen- tal Microbiology , 64 (8), 3079–3083. https://doi.org/10.1128/ AEM.64.8.3079-3083.1998 Gronewold, A.D., Sobsey, M.D., & McMahan, L. (2017). The com- partment bag test (CBT) for enumerating fecal indicator bacte- ria: Basis for design and interpretation of results. Science of the Total Environment , 587–588 , 102–107. https://doi.org/10.1016/j. scitotenv.2017.02.055 Gronewold, A.D., & Wolpert, R.L. (2008). Modeling the relationship between most probable number (MPN) and colony-forming unit (CFU) estimates of fecal coliform concentration. Water Research , 42 (13), 3327–3334. https://doi.org/10.1016/j.watres.2008.04.011 Haberecht, H.B., Nealon, N.J., Gilliland, J.R., Holder, A.V., Runyan, C., Oppel, R.C., Ibrahim, H.M., Mueller, L., Schrupp, F., Vilchez, S., Antony, L., Scaria, J., & Ryan, E.P. (2019). Antimicrobial-resis- tant Escherichia coli from environmental waters in Northern Colo- rado. Journal of Environmental and Public Health , Article 3862949. https://doi.org/10.1155/2019/3862949 Organisation for Economic Co-operation and Development. (2019). Antimicrobial resistance—Tackling the burden in the European Union.

https://www.oecd.org/en/publications/antimicrobial-resistance- tackling-the-burden-in-the-european-union_33cbfc1c-en.html Sargeant, J.M., O’Connor, A.M., & Winder, C.B. (2019). Editorial: Systematic reviews reveal a need for more, better data to inform antimicrobial stewardship practices in animal agriculture. Animal Health Research Reviews , 20 (2), 103–105. https://doi.org/10.1017/ S1466252319000240 Stauber, C., Miller, C., Cantrell, B., & Kroell, K. (2014). Evaluation of the compartment bag test for the detection of Escherichia coli in water. Journal of Microbiological Methods , 99 , 66–70. https://doi. org/10.1016/j.mimet.2014.02.008 Wang, A., McMahan, L., Rutstein, S., Stauber, C., Reyes, J., & Sobsey, M.D. (2017). Household microbial water quality testing in a Peru- vian demographic and health survey: Evaluation of the compart- ment bag test for Escherichia coli . The American Journal of Tropical Medicine and Hygiene , 96 (4), 970–975. https://doi.org/10.4269/ ajtmh.15-0717 World Health Organization. (2016). Global action plan on antimi- crobial resistance . https://www.who.int/publications/i/item/978924 1509763 World Health Organization. (2021). WHO integrated global surveil- lance on ESBL-producing E. coli using a “One Health” approach: Implementation and opportunities . https://iris.who.int/bitstream/ handle/10665/340079/9789240021402-eng.pdf

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Open Access

An Overview of Major Occupational Lung Diseases

Yet new and uncharacterized agents and hazardous materials continue to be intro- duced into industries, supporting the need for more research in the field (Cullinan et al., 2017; De Matteis et al., 2017; Fazen et al., 2020). Therefore, it is essential to con- tinue to research occupational lung diseases, which are one of the most common classes of occupationally induced injuries (Perlman & Maier, 2019; Rushton, 2017; Sirajuddin & Kanne, 2009). Of the 140 million U.S. workers who are at risk for occupational injuries and illness, approximately 1 mil- lion report occupational exposure-related illnesses, including respiratory diseases (Goldyn et al., 2008). Despite workplace improvements—from technological advances to preventive mea- sures and government enforcement of indus- trial standards and regulations—occupational diseases remain a major challenge (Cullinan et al., 2017; Rushton, 2017; Sirajuddin & Kanne, 2009). The cost of healthcare remains high, and occupational lung disease is not an exception. According to the Centers for Dis- ease Control and Prevention (CDC), medical expenses in 2017 for work-related asthma and COPD were $7 billion and $5 billion, respec- tively (Syamlal et al., 2020). Moreover, Goldyn et al. (2008) estimated that $26 billion is spent annually for occupational exposure-related illness, which includes respiratory diseases. Furthermore, data from research focusing on Great Britain, Canada, and France indicate that 2–5% of the cancer burden is associ- ated with occupational exposures (Olsson & Kromhout, 2021). In this article, we base our evaluation on a literature search of major occupational lung diseases. We highlight current information and discuss the rationale and available preven- tive strategies and regulations to prevent occu- pational exposures and protect all workers. Alexander C. Ufelle, MBBS, MPH, PhD Department of Public Health Sciences, Slippery Rock University Angela Mattis Bernardo, PhD Department of Safety Management, Slippery Rock University Adelle Williams, MBA, PhD Department of Public Health Sciences Slippery Rock University

Abstract Occupational lung diseases result from worker exposure in occupational settings to unhealthy environments and agents, such as silica dust, antigens, coal dust, washed coal/mixed dust, asbestos, and beryllium. Most of these conditions have long latency periods, with disease manifesting years after exposure. Approximately 1 million workers in the U.S. report occupational exposure-related illnesses, including respiratory diseases. We evaluated major occupational lung diseases via an extensive literature review and present here advances in diagnosing major occupational lung diseases, preventive strategies, and regulatory considerations for maintaining a healthy workforce. We include the widely studied occupational lung diseases asbestosis, coal workers’ pneumoconiosis and all other pneumoconioses, silicosis, byssinosis, malignant mesothelioma, hypersensitivity pneumonitis, and work-related asthma. The chemistry and physical properties of exposed materials play a role in the severity and pathogenesis of most occupational lung diseases. Knowledge of clinical signs and symptoms of these diseases, exposure history, and consensus diagnostic tools and criteria are crucial for accurate diagnosis, early detection, management, and improved outcomes. Further, regulatory agencies and other interested parties need to develop new and improved surveillance strategies, exposure limits, and technological and industrial safety measures, as well as implement regulations to guide industries and provide recommendations to protect all workers and reduce disease burden. Keywords: diagnosis, disease burden, occupational lung diseases, prevention, regulations, latency period

Introduction Widely studied occupational lung diseases include asbestosis, coal workers’ pneumoco- niosis (CWP) and all pneumoconioses, sili- cosis, byssinosis, malignant mesothelioma, hypersensitivity pneumonitis, asthma, chronic obstructive pulmonary disease (COPD), and lung cancer (Cullinan et al., 2017; Perlman & Maier, 2019; Reid & Reid, 2013; Schwartz & Peterson, 1998; Sirajud- din & Kanne, 2009). Occupational lung diseases result from exposure of workers in

the occupational setting to agents and condi- tions such as silica dust, antigens, coal dust, washed coal/mixed dust, asbestos, beryllium, and metals (Perlman & Maier, 2019; Sira- juddin & Kanne, 2009). Occupational lung diseases are avoidable by preventing worker exposure to workplace hazards (De Matteis et al., 2017), which can be accomplished by eliminating the hazards and using engineer- ing controls, administrative controls, and personal protective equipment (PPE) such as respiratory protective equipment.

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