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David Kay

Publications and source records attributed to David Kay.

15 recordsLinked to original sources
PubMed2006

Reply to comments on "Derivation of numerical values for the World Health Organization guidelines for recreational waters".

The contribution addressed reveals an optimistic design philosophy likely to systematically underestimate risk in epidemiologic studies into the health effects of bathing water exposures. The authors seem to recommend that data on the 'exposure' measure (i.e. water quality) in such studies should be acquired in a similar manner to that used for regulatory sampling. This approach may compromise the quality of the epidemiologic investigations undertaken. It may result in imprecise estimates of exposure because it ignores the fact that regulatory timescales and spatial resolution (even if artificially compressed to a bathing day) can mask large spatial and temporal variability in water quality. If this variability is ignored by taking some mean value and attributing that to all of those exposed in a period at a study location, many bathers may be misclassified and the studies may be biased to a 'no-effect' conclusion. A more appropriate approach is to maximise the precision of the epidemiologic investigations by measurement of individual exposure (or water quality) at the place and time of the exposure, as has been done in randomised volunteer studies in the UK and Germany. The precise epidemiologic relationships linking 'exposure' with 'illness' can then be related to the probability of exposure to particular water quality by a 'normal bather' using the known probability distribution of the exposure variable (i.e. faecal indicator concentration) in the regulated bathing waters. We suggest that any research protocol where poor sampling design for water quality assessment is justified because regulatory monitoring is equally imprecise may be fundamentally flawed. The rationale for this assessment is that the epidemiology is the starting point and evidence-base for 'standards'. If precision is not maximised at this stage in the process it compromises the credibility of the standards design process. The negative effects of the approach advocated in this 'comment' are illustrated using published research findings used to derive the figures illustrated in Wymer et al. [2005. Comment on derivation of numerical values for the World Health Organization guidelines for recreational waters. Water Research 39, 2774-2777].

Environmental Exposure↗
PubMed2006

Processes driving the episodic flux of faecal indicator organisms in streams impacting on recreational and shellfish harvesting waters.

Understanding the process controls on episodic fluxes of faecal indicator organisms (FIOs) is becoming increasingly important for the sustainable management and accurate modelling of water quality in both recreational and shellfish harvesting waters. Both environments exhibit transitory non-compliance with microbiological standards after rainfall episodes despite significant expenditures on control of sewage derived pollutant loadings in recent years. This paper demonstrates the role of wave propagation in the entrainment of FIOs from river channel beds as a contributor to episodes of poor microbial water quality. Previously reported data is reviewed in the light of relationships between wave and mean water travel velocities. High flows and rapid changes in river flow, driven by releases of bacterially pure reservoir water, resulted in elevated FIO concentrations and transient peaks in concentration. The new interpretation of these data suggest three modes of entrainment: (i) immediate wave-front disturbance, (ii) wave propagation lift and post-wave transport at mean flow velocity, and (iii) stochastic erosional mechanisms that maintain elevated bacterial concentrations under steady high flow conditions. This is a significant advance on the previously proposed mechanisms. Understanding these mechanisms provides an aid to managing streams intended for recreational use and emphasises the need to control the timing of high flow generation prior to use of the water body for e.g. canoeing events. In addition the processes highlighted have relevance for the protection of shellfish nurseries, drinking water supply intakes and episodes of poor bathing water quality, and associated health risks.

Animals↗
PubMed2005

Risk perception bias, self-reporting of illness, and the validity of reported results in an epidemiologic study of recreational water associated illnesses.

Epidemiologic studies of water associated illness often have to rely on self-reported symptoms of the outcome illness(es) under study. Individual participant's perception of risk, in theory, can affect the validity of self-reported symptoms. The magnitude and effect of possible "risk perception bias" was evaluated as part of a series of randomized trials designed to assess infectious disease transmission via exposure to marine recreational waters with modest sewage contamination. All study subjects were blinded to both their individual indices of exposure and the outcome illnesses under study. Of the five outcome illnesses studied, the effect of "risk perception bias" only effected one: skin ailments. Although analysis of crude rates of skin ailments showed the exposed group (bathers) to be 3.5 times more likely to report skin ailments relative to the non-exposed (non-bathers), when the data was stratified by any perceived health risk of bathing in such waters, this association was shown to be spurious in nature. Bathers having pre-conceived notions of any health risk due to the exposure were 10.63 times more likely to report skin ailments relative to the unexposed (non-bathers) (95% CI 2.36-47.8, P = 0.0002), while bathers without any pre-conceived notion of risk were no more likely to report skin ailments relative to non-bathers (OR = 0.60, 95% CI 0.11-3.24, P = 0.71). Further stratification by exposure grouping showed bathers with pre-conceived notions of excess risk to be 4.78 times more likely to report skin ailments relative to bathers without any notion of excess risk (95% CI 1.04-21.86, P = 0.03), while among non-bathers those with pre-conceived notions of risk were 3.70 times less likely to report skin ailments relative to non-bathers without any pre-conceived notion of risk (95% CI 0.70-19.60, P = 0.10). This study shows that "risk perception bias" can be strong enough to lead to spurious associations in the presence of self-reported symptoms, and should be controlled for in future epidemiologic studies of recreational water associated illnesses and other water associated environmental exposures where the use of self-reported symptoms cannot be avoided.

Bias↗
PubMed2005

Sustainable reduction in the flux of microbial compliance parameters from urban and arable land use to coastal bathing waters by a wetland ecosystem produced by a marine flood defence structure.

'Natural' treatment systems such as wetlands and reed beds have been proposed as sustainable means of reducing fluxes of faecal indicator organisms (FIOs) to recreational and shellfish harvesting waters. This is because FIO fluxes to coastal waters from both point (effluent) and diffuse (catchment) sources can cause non-compliance with microbiological standards for bathing and shellfish harvesting waters. The Water Framework Directive requires competent authorities in the member states to manage both point and diffuse sources of FIOs in an integrated manner to achieve compliance with 'good' water quality as defined in a series of daughter Directives. This study was undertaken to investigate the relative sources of FIOs to the popular bathing waters around Clacton, UK. In this predominantly arable (mainly cereal cropping) farming area, the principal land use predictor, explaining 76% of the variance in geometric mean presumptive Escherichia coli concentration at sub-catchment outlets during the bathing season, was the proportion of built-up (i.e. urbanised) land in each sub-catchment. This new finding contrasts with earlier studies in livestock farming regions where the proportion of improved grassland has proven to be the strongest predictor of microbial concentration. Also novel in this investigation, a flood defence wall has been built creating a wetland area which discharges every tidal cycle. The wetland produces over 97% reduction in the flux and concentrations of FIOs to the marine recreational waters. Also, FIO concentrations in water draining through the wetland to the sea were similar to concentrations measured in six UK sewage treatment plant effluents subject to secondary (biological) treatment followed by UV disinfection.

Agriculture↗
PubMed2005

Predicting faecal indicator fluxes using digital land use data in the UK's sentinel Water Framework Directive catchment: the Ribble study.

The Ribble drainage basin is the single UK sentinel study area chosen for examining the implementation of the EU Water Framework Directive (WFD 20/60/EC). The study which has generated the data for this paper was initiated to quantify 'catchment-derived' fluxes of faecal indicators originating from both point and diffuse sources to inform the competent authorities on the potential for, and prioritization of, further options for reducing the faecal indicator loadings to this crucial coastal environment. It represents the first UK drainage basin-scale 'profile' of faecal indicator sources as recommended by WHO [1999. Health Based Monitoring of Recreational Waters: The Feasibility of a New Approach; the "Annapolis Protocol". World Health Organisation Geneva, Switzerland; 2003. Guidelines for Safe Recreational-Water Environments Volume 1: Coastal and Fresh-Waters. World Health Organisation Geneva, Switzerland] and incorporated into current drafts of the revised Bathing Water Directive [Anon, 2004. Council of the European Communities Amended proposal for a Directive of the European Parliament and of the Council concerning the management of bathing water quality. Brussels 23rd June]. This paper focuses on the relationships between land use and faecal indicator organism concentrations in surface waters within this very large drainage basin (1583 km2) containing some extensive urban areas. A geographical information system comprising readily available digital elevation, remotely sensed land cover and digital map data was used to generate the land use variables for subcatchments draining to 41 locations across the study area. Presumptive concentrations of coliforms, Escherichia coli and enterococci (colony forming unit (cfu) 100 ml(-1)) were measured at each location on at least 20 occasions over a 44-day period within the 2002 bathing season. The sampling programme targeted hydrograph events. Hydrometric records were used to allocate results as either base flow or high flow. At each site, geometric mean faecal indicator organism concentrations were significantly elevated at high flow compared to base flow. Stepwise regression modelling produced statistically significant models predicting geometric mean base and high-flow faecal indicator organism concentrations from land use variables (r2: 49.5-68.1%). The dominant predictor variable in each case was the proportion of built-up land in subcatchments, suggesting that this land use type, with associated sewage-related inputs, is a critical source of faecal indicator organisms in this drainage basin.

Biomarkers↗
PubMed2005

Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis.

Many studies have reported the results of interventions to reduce illness through improvements in drinking water, sanitation facilities, and hygiene practices in less developed countries. There has, however, been no formal systematic review and meta-analysis comparing the evidence of the relative effectiveness of these interventions. We developed a comprehensive search strategy designed to identify all peer-reviewed articles, in any language, that presented water, sanitation, or hygiene interventions. We examined only those articles with specific measurement of diarrhoea morbidity as a health outcome in non-outbreak conditions. We screened the titles and, where necessary, the abstracts of 2120 publications. 46 studies were judged to contain relevant evidence and were reviewed in detail. Data were extracted from these studies and pooled by meta-analysis to provide summary estimates of the effectiveness of each type of intervention. All of the interventions studied were found to reduce significantly the risks of diarrhoeal illness. Most of the interventions had a similar degree of impact on diarrhoeal illness, with the relative risk estimates from the overall meta-analyses ranging between 0.63 and 0.75. The results generally agree with those from previous reviews, but water quality interventions (point-of-use water treatment) were found to be more effective than previously thought, and multiple interventions (consisting of combined water, sanitation, and hygiene measures) were not more effective than interventions with a single focus. There is some evidence of publication bias in the findings from the hygiene and water treatment interventions.

Child↗
PubMed2005

An estimation of the global burden of disease due to skin lesions caused by arsenic in drinking water.

The global burden of disease due to skin lesions caused by arsenic in drinking water was estimated by combining country-based exposure data with selected exposure-response relationships derived from the literature. Populations were considered to be exposed to elevated arsenic levels if their drinking water contained arsenic concentrations of 50 microg I(-1) or greater. Elevated arsenic concentrations in drinking water result in a significant global burden of disease, even when confining the health outcome to skin lesions. The burden of disease was particularly marked in the World Health Organization (WHO) comparative risk assessment (CRA) 'Sear D' region, which includes Bangladesh, India and Nepal. Unsurprisingly, Bangladesh was the worst affected country with 143 disability adjusted life years (DALYs) per 1,000 population. Although this initial estimate is subject to a large degree of uncertainty, it does represent an important first step in allowing the comparison of the problem relating to elevated arsenic in drinking water to other environmental health outcomes.

Adolescent↗
PubMed2004

Derivation of numerical values for the World Health Organization guidelines for recreational waters.

In April 2001, draft 'Guidelines' for safe recreational water environments were developed at a World Health Organization (WHO) expert consultation. Later the same month, these were presented and discussed at the 'Green Week' in Brussels alongside the on-going revision of the European Union Bathing Water Directive 76/160/EEC. The WHO Guidelines cover general aspects of recreational water management as well as define water quality criteria for various hazards. For faecal pollution, these include faecal indicator organism concentrations and an assessment of vulnerability to faecal contamination. Central to the approach set out in the WHO Guidelines are: (i) the concept of beach profiling to produce a 'sanitary inspection category' which implies a priori hazard assessment as a core management tool and (ii) the prediction of poor water quality to assist in real time risk assessment and public health protection. These management approaches reflect a harmonized approach towards the assessment and management of risk for water-related infectious disease being applied by WHO. Numerical microbiological criteria for intestinal enterococci are proposed in the new Guidelines. These were developed using a novel approach to disease burden assessment, which has been applied to both recreational waters and urban air quality. This paper explains the scientific rationale and mathematical basis of the new approach, which is not presented in the WHO Guidelines for recreational waters.

Cities↗
PubMed2003

Morton's neuroma.

Morton's neuroma is a common problem. Progress has been made in the understanding of this frequent problem since Morton's original description and treatment. Today, we accept a failure rate of 15% to 20%, even in the best of series. We must ask ourselves if this is good enough. What can we do to achieve an acceptable failure of 5% or less? How can we improve? Only through an honest analysis and discussion can we improve the care that we deliver.

Fibrosis↗
PubMed2003

Natural history of untreated otitis media.

OBJECTIVE/HYPOTHESIS: Data from cohort studies and untreated groups in randomized controlled trials can be identified through systematic literature review and synthesized with meta-analysis to estimate natural history of acute otitis media (AOM) and otitis media with effusion (OME). STUDY DESIGN: Systematic literature review and meta-analysis. METHOD: Source articles were identified by MEDLINE search through August 2002 plus manual crosschecks of bibliographies and published meta-analyses. Data were abstracted independently by two investigators and combined with random effects meta-analysis to estimate spontaneous resolution, 95% confidence intervals (CI), and heterogeneity. Sensitivity analysis was performed. RESULTS: Sixty-three articles met inclusion criteria. AOM symptoms improved within 24 hours without antibiotics in 61% of children (95% CI, 50-72%), rising to 80% by 2 to 3 days (95% CI, 69-90%). Suppurative complications were comparable if antibiotics were withheld (0.12%) or provided (0.24%). Children entered recurrent AOM trials with a mean rate of 5.5 or more annual episodes but averaged only 2.8 annual episodes while on placebo (95% CI, 2.2-3.4). No AOM episodes occurred in 41%, and only 17% remained otitis prone (3 or more episodes). OME after untreated AOM had 59% resolution by 1 month (95% CI, 50-68%) and 74% resolution by 3 months (95% CI, 68-80%). OME of unknown duration had 28% spontaneous resolution by 3 months (95%, CI 14-41%), rising to 42% by 6 months (95% CI, 35-49%). In contrast, chronic OME had only 26% resolution by 6 months and 33% resolution by 1 year. CONCLUSIONS: The natural history of otitis media is very favorable. Combined estimates of spontaneous resolution provide a benchmark against which to judge new or established interventions. The need for surgery in children with recurrent AOM or chronic OME should be balanced against the likelihood of timely spontaneous resolution and the potential risk of learning, language, or other adverse sequelae from persistent middle ear effusion. Further research is needed to identify prognostic factors that can target children unlikely to improve spontaneously for earlier intervention.

Child↗
PubMed2002

Faecal-indicator concentrations in waters draining lowland pastoral catchments in the UK: relationships with land use and farming practices.

Faecal-indicator budget studies have shown marine bathing water quality at two small UK coastal resorts, Staithes and Newport, to be adversely affected by riverine inputs from lowland pastoral catchments (J. Chartered Inst. Water Environ. Mangt. 12 (1998) 414). The present paper reports on presumptive coliform (PC), presumptive Escherichia coli (PE) and presumptive streptococci (PS) concentrations at 43 sampling points on watercourses within these catchments, and on their relationship with land use and livestock-related management practices, such as grazing and slurry/manure applications. The results show > 10-fold elevations in geometric mean faecal-indicator concentrations under high-flow conditions, compared with low flow, with maximum high-flow geometric mean PC, PE and PS concentrations of 2.6 x 10(6), 1.8 x 10(6) and 4.4 x 10(5) cfu/100 ml, respectively. High-flow geometric mean concentrations exhibit highly significant positive correlations with land use/management variables associated with intensive livestock farming, both within the individual catchments and in the two combined. Additional factors, such as antecedent weather conditions and topography, contribute to inter-catchment variability in water quality. Although inputs from diffuse and point sources of pollution were not quantified, point sources (e.g. runoff from farm yards) seem likely to be significant. The findings suggest that it may be possible to develop generic statistical models to predict microbial water quality from land use and farm management data. They also provide indirect evidence that channel bed sediment 'stores' closely reflect land use within their catchments and that there is little die-off of organisms along watercourses.

Agriculture↗
PubMed2002

Estimating the burden of disease from water, sanitation, and hygiene at a global level.

We estimated the disease burden from water, sanitation, and hygiene at the global level taking into account various disease outcomes, principally diarrheal diseases. The disability-adjusted life year (DALY) combines the burden from death and disability in a single index and permits the comparison of the burden from water, sanitation, and hygiene with the burden from other risk factors or diseases. We divided the world's population into typical exposure scenarios for 14 geographical regions. We then matched these scenarios with relative risk information obtained mainly from intervention studies. We estimated the disease burden from water, sanitation, and hygiene to be 4.0% of all deaths and 5.7% of the total disease burden (in DALYs) occurring worldwide, taking into account diarrheal diseases, schistosomiasis, trachoma, ascariasis, trichuriasis, and hookworm disease. Because we based these estimates mainly on intervention studies, this burden is largely preventable. Other water- and sanitation-related diseases remain to be evaluated. This preliminary estimation of the global disease burden caused by water, sanitation, and hygiene provides a basic model that could be further refined for national or regional assessments. This significant and avoidable burden suggests that it should be a priority for public health policy.

Adolescent↗