Edo McGowan                             PATHOGENS IN CALIFORNIA RECLAIMED TITLE 22 WATER

This discussion relates to pathogens noted in Title 22 water. Title 22 is, according the California Department of Health
Services, produced under a universal criteria, a yardstick that fits the whole state. Thus through these standards,
Title 22 maintains a uniformity no matter where it is produced. It will be noted that certain levels of indicator bacteria
are allowed to survive within Title 22 water. What fails to be discussed by the proponents of this water, however, are
some critical matters related to this survival.

The interesting question that must then be placed before the proponents of the current standards might include the
following. The indicators are vegetative bacteria that merely require low-level disinfection. What then of the more
robust? There are pathogens that require high-level disinfection such as those that would be noted on semi-critical
surgical devices. These medical devices include the scopes inserted into the lower and upper gastrointestinal tract.
Thus, if these low-level vegetative bacteria are allowed to survive---then is it not unreasonable to assume that the
more robust will survive also and because of their robustness do so in vastly greater numbers. Sewer plants do not
come anywhere close to attaining the equivalent of high-level disinfection.

Sewer plants also do a dismal job of taking pharmaceuticals out of the discharged effluent. Many of these drugs pass
essentially unchanged from your body into the sewer. If these entrained drugs are constantly added to irrigation
systems, as happens, then some can build up to rather high levels in the soil. This has been verified by studies.
These drugs have bioactive properties---that is what an antibiotic is all about. But when administered for a particular
medical problem, it is under controlled conditions. Out in the environment, it is not controlled. There are studies that
look at subtherapeutic levels of these pharmaceuticals in the environment and the development of resistance
accruing to the release from sewer plants. Contrary to popular myth, sewer plants do not consistently kill pathogens
and in many instances the levels of antibiotic resistance are augmented by the very process of sewer treatment. This
is something that most sewer plant operators fail to comprehend.

As noted above, because of the constant application of "treated" wastewater, some of the drugs build up in the soils.
Erythromycin, for example builds up and this, as will be noted below may be a critical flaw. The level of organic matter
in the soil also affects this retention. There are issues of cross-resistance on top of that. Then, certain cultural
practices such as using herbicides will also see the build up of a different type of resistance in the soil microbes, but
the cellular machinery to deal with herbicides is not that much different that from that seen in antibiotic resistance.
Thus what one finds is often a loaded and primed soil system and then when a human superbug from sewage is
introduced, the system being already primed may explode. Thus colonies of serious pathogens can be established in
soils that later in the day see contact sports, a skid across the turf, the introduction of bacteria into a cut, and there is
your potential dead body. There are also papers in the literature that also follow some of these pharmaceuticals into
the ground water.

Monday the 25th of this month, the Santa Barbara News Press carried a front page story on the run away levels of
antibiotic resistant bacteria (superbugs) found now within the community at large. Just a few years back this was a
problem confined only to hospitals. But then hospitals do flush some pretty horrific pathogens to the local sewers and
these are all mixed with other microbes and share the genetic information. The biological process of a sewer plant is
dependent upon lots of bacteria to digest the organic matter. The designers of sewer plants did not and do not really
understand the biology involved at the cellular and molecular level of gene transfer. There is nothing in the state’s
regulations controlling the licensing of sewer plant operators that would require them to, even from a rudimentary
level, understand this. I have checked on this and the state indicated that there was no requirement for that
information. Thus the operators of sewer plants don’t know that they don’t know.

When the solids including the urine and fecal material are mixed in a sewer plant, the mixing breaks up some cells and
the resultant soup includes genetic fragments of bacteria and viruses. This fractured cellular information may be for
virulence or drug resistance and is thus available for reuptake by others, including the gut bacteria of humans and
also soil bacteria. There is a furious trades fair of genetic exchange within sewer plants between bacteria and viruses.
Transfer of genetic information freely occurs between distantly related organisms. The genetic fragments are also not
amenable to levels of chlorine used by the wastewater industry. This is why Amy Pruden was able to see that
information, called antibiotic resistant genes (ARGs) pass through sewer plants and then later be noted in drinking

In Santa Barbara we tested some disinfected tertiary recycled Title 22 water, as used for irrigation on contact sports
playing fields and parks. It showed multi-drug resistance. The interesting thing here was that a day or two later we saw
secondary growth within the clear areas on the Mueller-Hinton plates. This may have been the resuscitation of
bacteria in the viable but non-culturable (VBNC) state and these also were resistant. Once in the VBNC state, the
standardized lab tests can not see these bacteria---they are "cloaked", to use Star Trek language. There are other
similar conditions and again the standard lab tests fail to see them. This has been reported for sewage sludge in
several papers, perhaps the most notable of which was WERF’s own paper by Higgins and Murthy. That paper
indicated that compared to standard lab tests, the actual counts of bacteria were several magnitudes higher---but
completely missed by the systems relying on the standards. This then raises some very serious questions about how
long this has been going on? Thus one must then ask-------- has there been a fiction in the ability to protect public
health, and if so ,why has it been allowed to continue?

Because Title 22 does not consider things like VBNC, it can not be said with any assurance that Title 22 is actually
protective of public health.

There are also shadow systems used by industry to make assumptions about viral removal. These levels of 5-log
removal assume that if the water has less that some number of indicator bacteria (but we now have reason to
question those levels) and that it has reached a certain reduction in turbidity, that there is an assumed reduction of
viral levels. But lab tests to actually ascertain viral levels are seldom run. By definition, if there is a 5-log reduction
[99.999%] then, by that definition there are "NO" viruses---this is a fairly major jump in logic. With many of existing
technologies, there remains to be a demonstrated correlation between turbidity and viral numbers. Thus while there
can be achievable reductions in turbidity, this may not assure a specific reduction in pathogens. Again the argument
from industry is "show us the dead bodies". But since many of the diseases associated with enteric viruses are not
reportable, this is a shill game.

Much of the data developed for this analysis was done by the Pomona Virus Study, a study dating back now some
time---1992. Much has been noted in newly emerging infectious diseases since that study. There are questions being
raised about membrane systems that were unknown when these studies were conducted in 1992. Thus there
questions, unanswered, about system trains of combining off the shelf water control components. Although each may
be individually approved, the combined effect may not have been put to a rigorous test. Also, please remember some
time had elapsed between the actual published 1992 study, the gathering of reference material and then the actual
vetting and final release. Thus some of the data upon which one relied back in 1992 might then have been a bit old at
the time.

Our local teaching hospital here in Santa Barbara, because the local levels of community acquired methicillin resistant
Staphylococcus aureus (CA MRSA) are high, has since about 2002 or 2003 been using vancomycin as a routine pre-
op prophylactic for certain surgical procedures. This is a worrisome situation because of the mixing of urine and fecal
material in the local sewer will see this genetic information shared and then the product goes out via Title 22 water on
the same parks and playing fields. Thus we may have a revolving door here with CA MRSA and don’t know it.
Vancomycin is not a benign drug and many adverse reactions can and do occur because of its use, including death.
Thus by putting poorly treated water out, we may be doing damage from several perspectives, yet those doing so
claim that all is well. One must then look at the economic incentives here as drivers.

How does this get to our gut bacteria or the soil bacteria? Fairly simple---in the water. But, you protest, there are no
dead bodies, and by the way, the water has passed all applicable state and federal standards?

These bacteria are in fact able to colonize environmental niches, including the delivery pipes through biofilms and
humans through ingestion. Once ingested, the genetic information may be transferred to normal flora, and
subsequently to pathogenic bacteria found in humans or animals, making later treatment with particular antibiotics
ineffective. Also one must consider transfer of genetic information from these organisms to more robust organisms as
highlighted by Sjolund et al. (2005) indicating that resistance in the normal flora, which may last up to four-years,
might contribute to increased resistance in higher-grade pathogens through interspecies transfer.

These authors go on to note that since populations of the normal biota are large, this affords the chance for multiple
and different resistant variants to develop. This thus enhances the risk for spread to populations of pathogens.
Furthermore, there is crossed resistance. For example, vancomycin resistance may be maintained by using
macrolides---e.g., eryhtromycin, possible by similar drugs such within this group such as Zithromax, Zitromax, Biaxin. It
will be remembered that erythromicin did build up in the soils.

Christopher Walsh (2003) in his medical text Antibiotics—Actions, Origins, Resistance, notes that resistance to
antibiotics is not a matter of IF but one of WHEN.

Schentag, et al. (2003), as found in Walsh, followed surgical patients with the subsequent results. Pre-op nasal
cultures found Staphylococcus aureus 100% antibiotic susceptible. Pre-op prophylactic antibiotics were administered.
Following surgery, cephalosporin was administered. Ninety percent of the patients went home at post-op day 2 without
infectious complications. Nasal bacteria counts on these patients had dropped from 10/5 to 10/3, but were now a mix
of sensitive, borderline, and resistant Staphylococcus sp. By comparison, prior to surgery, all of the patients’
Staphylococcus samples had been susceptible to antibiotics. For the patients remaining in the hospital and who were
switched on post-op day 5 to a second generation cephalosporin (ceftazidine), showed bacterial counts up 1000-fold
when assayed on post-op day 7 and most of these were methicillin resistant Staphylococcus aureus (MRSA). These
patients were switched to a 2-week course of vancomycin. Cultures from those remaining in the hospital on day 21,
revealed vancomycin resistant enterococcus (VRE) and candida. Vancomycin resistant enterococci infections can
produce mortality rates of between 42 and 81%.

Note in the above, that these patients harbored NO resistant bacteria in their nasal cavities upon entry to the hospital.
But what would be the result if there had been inadvertent acquisition of resistance from environmental contamination
such as through Title 22 water?

In closing, it should be noted that I am an advocate of the sensible use of recycled water, but  recycling needs much
more thought and the rush to short-term profit seems to have taken first place over intelligent thought and full
consideration of the costs to public health. Did that need to happen?

Dr. Edo McGowan, Medical Geo-hydrology

Carpinteria, California