Experts Consultation Development of a Protocol for Epidemiological Investigations in Recreational Bathing Waters

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1 WHO Guidelines for Safe Recreational Water Environments Experts Consultation Development of a Protocol for Epidemiological Investigations in Recreational Bathing Waters Mexico City, Mexico, Gerencia de Saneamiento y Calidad del Agua Comisión Nacional del Agua November 2005 Summary Report APPENDIX 1. Agenda Prepared by Keira Robinson (CEPIS-BS/SDE/PAHO) Henry Salas (CEPIS-BS/SDE/PAHO) 2006

2 APPENDIX 1 - Agenda WHO Guidelines for Safe Recreational Water Environments Experts Consultation Development of a Protocol for Epidemiological Investigations in Recreational Bathing Waters Mexico City, Mexico, Gerencia de Saneamiento y Calidad del Agua Comisión Nacional del Agua November 2005 Monday, November 28 08:00-09:00 Inscriptions 09:00-09:15 Inauguration: Agenda Dr. Felipe I. Arreguín Cortés, Technical Subdirector, CNA Ing. Enrique Mejía Maravilla, Manager of Sanitation and Water Quality, CNA Dr. Jacobo Finkelman, Representative in Mexico, PAHO/WHO 09:15 10:00 WHO Guidelines for Safe Recreational Water Environments (GSRWE). Water Quality Monitoring of Recreational Bathing Waters; the Annapolis Protocol. Microbiological Water Quality Standards in Latin America and the Caribbean. Henry Salas, CEPIS-BS/SDE/PAHO-Peru 10:00-10:45 Scientific Basis for WHO Guidelines for Safe Recreational Water Environments. Randomized Controlled Studies David Kay, University of Wales, Great Britain 10:45 11:15 Recess 11:15 11:45 Epidemiological Studies Conducted in Germany. Fresh Water Albrecht Wiedenmann, Public Health Department of the Administrative District Loerrach, Germany 11:45 12:30 Epidemiological Studies conducted in the USA. Prospective Cohort Studies. Past and present. Alfred Dufour, EPA, USA

3 12:30 13:00 Pathogen/Indicator Investigations Conducted in the Tropical Waters of Australia. Nicholas J. Ashbolt, University of New South Wales, Australia 13:00 13:30 Epidemiological Studies conducted in Brazil. Prospective Cohort Studies. Claudia Condé Lamparelli, CETESB, Brazil 13:30 14:45 Lunch 14:45-15:00 Studies on Exposure and Effects on Health from Enterococcus in Marine Waters. Alejandra Martínez, COFEPRIS 15:00 15:15 Quantifying Microbiological Risk in Bathing Beaches in Sinaloa, Mexico. Cristobal Chaidez, Centro de Investigación en Alimentación y Desarrollo, Sinaloa 15:15 15:30 Evaluating Risk in Lake Chapala. Juana Cortés. Instituto Mexicano de Tecnología del Agua. 15:30 15:45 Detection of enteric viruses in recreational waters. Ana Espinosa. Instituto de Ecología. UNAM. 15:45 16:00 Recess 16:00 16:15 Evaluation of the microbiologic risk: enterococus - fecal coliform. Irma Rosas. University Environmental Program, UNAM. 16:15 16:30 Epidemiological Surveillance. Matiana Ramírez. COFEPRIS 16:30 16:45 New measurement techniques for bacterial indicators. Alfred P. Dufour, EPA, USA 16:45 17:15 Straw Man: Proposed Epidemiological Protocol - Mexico: Health Risk Evaluation Associated with the Water Quality of the Beaches of Banderas Bay. Saúl Guerrero, Centro Universitario de la Costa, Universidad de Guadalajara. 17:15 18:00 Discussion: Work Plan, Objectives and Goals 2

4 Tuesday, November 29 08:30 10:00 Formulation of the study question or hypothesis What are the objectives of the study? Local endemic diseases: prevalence and incidence of disease. Disease source - human excreta vs. animal excreta; diffuse vs. point source Tropical waters: prevalence of pathogen, pathogen survival. The type and length of exposure to recreational water The setting - less developed country vs. more developed country; tropical vs. semi-tropical vs. temperate; dry vs. humid Strengthening epidemiological data base use of complementary information What are the gaps in the current approaches? What tools are needed to help fill the gaps? Linking existing epidemiological data to forecast disease- endemic disease; outbreaks. Risk assessment (rainfall, seasonal, river flows, etc.) Causative disease agent (e.g. Rotavirus) 10:00 10:30 Recess 10:30 12:00 Selection of study methodology, populations and study samples/ethics and feasibility Type of study design (Randomized Controlled versus Prospective Cohort Approaches. Hybrid? Site-specific studies?) Sample recruitment methodology including the interview process that will be utilized pre-exposure and post-exposure. Will advertisement such as flyers be used? Will there be remuneration for the participants? Issues of communication limitations in Latina America and the Caribbean (LAC). 12:00 13:30 Lunch 13:30 15:00 Ethics and Feasibility (Continued) Ethics and exclusion criteria: Is it feasible and ethical to include children/toddlers/the elderly and those who are immuno-suppressed (chronic or acute disease) in the study? Should age be included in the exclusion criteria? If so, what age cutoff should be employed? Adequate sample size by age group? 3

5 What about the ethics of conducting a study in beaches that are known to have extremely high levels of contamination? Cutoff level for suitable recreational use Should tourists be included? Perceived problem for tourists, i.e. Am I using a contaminated beach? How to conduct follow-up interviews with tourists. Sample size and power calculations 15:00 15:30 Recess 15:30 17:00 Selection of indicators of exposure: Indicator organisms and pathogens selection for epidemiological studies Exposure criterion: Exposed and unexposed groups criteria. Measurement of Exposure Analytical methodologies. Rapid methods? Reliability of measurements in LAC Measurement of Disease Burden Outcome variables: A clear, specific definition of the outcomes (gastrointestinal (GI) disease, acute fibril respiratory illness, ear infections, skin infections, etc) to be monitored is required. Definition of follow-up period to assess outcome measure? How will follow-up interviews be conducted? Self report or personal interview? Wednesday, November 30 08:30 10:00 Confounding Factors Certain questions should be included in the pre and post interview for the purpose of adjusting for confounding factors in multivariate logistic model: Diet: food consumption the day of the study, and during follow-up periods (although this will be subject to recall bias) Contact with other sick persons (whether or not someone they have been in frequent contact with has symptoms of GI disease, ear infections, fever, etc) Serious acute infections or diseases, endemic diseases Tourist/resident distinctions Social/economic class distinctions, i.e. high, middle, low income status. Confounding factors for poverty classes? 10:00 10:30 Recess 4

6 10:30 12:00 Analysis of the relationship between exposure and disease Descriptive statistics, i.e. arithmetic vs geometric mean vs percentile Multivariate logistic regression (including confounders, effect modifiers) Proportional hazards methods? 12:00 13:30 Lunch 13:30 15:00 Evaluation of the role of bias Types of bias to consider: Diet: food consumption the day of the study, and during follow-up periods (although this will be subject to recall bias) recall (Due to participant self reporting of symptoms) misclassification (of both exposure and disease): For exposure variable (organism concentration) For outcome (disease) variable: Bias may occur due to self report of disease and/or non-specific criteria to define disease outcome How to minimize bias in the design? In the analysis? Evaluation of the role of chance 15:00 15:30 Recess 15:30 16:45 Wrap up Presentation of General Aspects of Proposed Protocol Representative of Experts 16:45 17:00 Closing 17:00 Trip to Acapulco Discussions & Conclusions. Future Roadmap Acapulco Meeting Discussion 5

Experts Consultation Development of a Protocol for Epidemiological Investigations in Recreational Bathing Waters

WHO Guidelines for Safe Recreational Water Environments Experts Consultation Development of a Protocol for Epidemiological Investigations in Recreational Bathing Waters Mexico City, Mexico, Gerencia de