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Testing can be performed using isolates from solid cian and the laboratorian and in the event that a specific labora- or liquid culture media and identification of these species can tory does not have the necessary technology for species identifi- be achieved within 2 hours buy alfuzosin 10mg lowest price prostate cancer 5 year survival rates. The size of effort for identification of that isolate as it would not likely be the restriction fragments is generally species specific (56–59) buy alfuzosin 10 mg with amex androgen hormone negative feedback. However buy discount alfuzosin 10 mg on line androgen hormone and acne, some taxa may require additional ing the need for speciation of that isolate. The controversy to all organisms (conserved regions) and also areas where nucle- primarily stems from the observation that, unlike M. In addition, no interstrain nucleotide sequence Susceptibility breakpoints have been defined in the laboratory difference value that unequivocally defines different species has to distinguish populations of mycobacteria that are labeled sus- been established for mycobacteria (48). One of the major and clarified, the clinician should use in vitro susceptibility data limitations of this system, however, is that the MicroSeq database with an appreciation of its limitations and with the awareness has only one entry per species (generally the type strain) (61). Although the caveat that each laboratory must validate each method for not routinely recommended, this differentiation may be each species tested, and quality control and proficiency testing important epidemiologically and, in the future, therapeuti- requirements should be enforced. Isolates from patients who previously received macrolide to facilitate identification of M. Communication between the clinician and laboratorian macrolide-containing regimens who relapse or fail after 6 is essential for determining the importance and extent of months of macrolide-containing therapy. Routine susceptibility testing of this species is macrolide-containing regimens for patients with dissemin- not recommended (43). Until further data are available, the isolate is found on subsequent testing to be macrolide resistant. If the isolate proves to be rifampin resistant, suscepti- species that are macrolide resistant (e. Susceptibility testing of these species is difficult even with multiple cultures of the same strain (43). Other methods have been used for ized guidelines for in vitro susceptibility procedures are not avail- strain comparison, including random amplified polymorphic able for testing these species (77–82). There are no current recommendations for one specific clude sputum production, fatigue, malaise, dyspnea, fever, he- method of in vitro susceptibility testing for fastidious moptysis, chest pain, and weight loss. Evaluation is often complicated by symptoms caused by coexisting lung diseases, such as bronchiectasis, chronic obstruc- 7. Physical findings are nonspecific and reflect underlying pul- monary pathology, such as bronchiectasis and chronic obstruc- tive lung disease. Pulsed-field gel electrophore- sis (nodular/bronchiectatic disease) (see the online supplement). These biopsies are performed because of the small size of the tissue findings correspond histopathologically to bronchiectasis, bron- sample) but demonstrates mycobacterial histopathology features chiolar and peribronchiolar inflammation, and granuloma for- (without a history of other granulomatous or mycobacterial dis- mation (94). Unfortunately, A plain chest radiograph may be adequate for evaluating many antigenic epitopes are shared by different mycobacterial patients with fibrocavitary disease. A single positive sputum culture, especially with a small number of organisms, is generally regarded as indetermi- 1. Overly rigorous criteria might delay or tive, subsequently developed new chest radiographic abnormali- prevent the diagnosis, with the subsequent risk for progressive tites. A limitation of all diagnostic criteria developed so mental contamination if the bronchoscopic specimens are far is that, by necessity, they were developed based on experience protected from tap water (see Health Care– and Hygiene- with common and well-described respiratory pathogens such as associated Disease and Disease Prevention). If a tissue times be made on the basis of smear and culture positivity or sample from a transbronchial, percutaneous, or open-lung biopsy negativity without quantitation. Pulmonary symptoms, nodular or cavitary opacities on chest radiograph, or a high-resolution computed tomography scan that shows multifocal bronchiectasis with multiple small nodules (A, I)* and 2. No pathologic studies have been done to demon- be helpful for making this decision. The significance of a single sputum specimen culture posi- absence of radiographic evidence of pulmonary disease, respira- tive for a nontuberculous mycobacterium is more uncertain. Given these considerations, the diagnosis of lung disease apy before species identification of the mycobacterial isolate. There have been with these clinical scenarios must be evaluated carefully, on an numerous reports of clinical deterioration and death temporally individual basis, and may require expert consultation. Smear results were cede any initiation of macrolide monotherapy, and cultures for positive in 26% of culture-positive specimens. Surgical airway disease and altered mucociliary clearance may be predis- resection, lobectomy or pneumonectomy, should be reserved for posing factors. Poor control of the mycobac- of patients on hospital wards for prolonged periods of time terial infection with medical management and, particularly, isola- raise questions about person-to-person transfer or nosocomial tion of M. During tential sources of concern as was noted in a recent study of periods of clinical decline while unresponsive to treatment an M. Occasionally, hypoxemic respiratory failure requires hospitalization or intensive care unit Hypersensitivity-like Disease admission. The water sources, this syndrome has been reported in at least one histopathology is that of nonnecrotizing granulomas although case associated with a household shower (137). Because of the necrotizing granulomas, organizing pneumonia, or interstitial potential for acquiring this disorder from multiple sources, it pneumonia may also be described in some patients (149). Even if nonspecific, identifying characteristic histopathol- bacteria are relatively resistant to disinfectants and may be able ogy on biopsy may be sufficient to raise suspicion for diagnosis. In addition, mycobacteria are also quite resistant to cases (see online supplement). Findings include diffuse infiltrates agents used for disinfection, including quaternary ammonium with prominent nodularity throughout all lung fields. Pulmonary function testing demon- chlorine would be expected to kill nonmycobacterial flora and strates mixed abnormalities. Blood tests are not sufficiently spe- therefore could permit the growth of mycobacteria in the absence cific to be of diagnostic value. Key elements to a diagnosis are a compatible clinical tients often enter the hot tub before bathing, adding contamina- history (including a hot-tub exposure), microbiology, radiographic tion. Interestingly, patients will often spend additional time in studies, and histopathology, when available. Mycobact- cess, infectious process, or a combination of inflammation and eria are also resistant to the heavy metals in metalworking fluids infection. Exposure to these aerosols leads to hypersensitivity-like treatment recommendations; therefore, recommendations are pneumonitis similar to that seen with hot-tub exposure but asso- based on expert opinion. Despite disinfection with multiple source (contaminated hot tub), the use of antimycobacterial ther- agents, M. Similarly, for metal grinders, avoidance of mycobacterial Patients who have colonization of their respiratory and gastrointes- (M. Corticosteroid tinal tracts are at higher risk of developing disseminated disease administration may also be associated with clinical improvement. For indoor pools and hot tubs, manufacturers universally recommend following regular maintenance procedures usually been less than 25 cells/ l (156, 157).

Tey are also being used as a To this can be added the costs borne by the individual effective alfuzosin 10 mg prostate cancer progression, requirement for participation in competitions for service such as private contributions to medical care best purchase alfuzosin mens health 12 week workout, and external contracts and as instruments for service-level self- costs to society buy generic alfuzosin 10mg androgen hormone menopause, such as losses of productivity and the assessment. Assessment of these wider costs to society may allow resources to be more efectively targeted. In the l Delivering prevention: a systems approach European countries for which information is available, the social cost of illicit drugs is estimated to be between 0. Environmental and universal approaches target entire populations, selective prevention targets vulnerable groups who may be at greater risk of developing drug use problems, and indicated prevention focuses on at-risk individuals. Quality standards currently exist in most European countries 63 European Drug Report 2017: Trends and Developments Many diferences exist between European countries in the Prevention approaches that target high-risk way prevention is addressed, with some tending to adopt neighbourhoods have been implemented in some broader community-based and environmental approaches countries, utilising new methods such as the redesigning (e. Provision for these types of interventions is based prevention programmes, characterised by strictly reported to be highest in the north and west of Europe (see defned content and delivery, can be an efective way to Figure 3. Provision Other countries have prioritised a broader systems of this type of intervention is limited in Europe, with only 4 approach to their prevention interventions, focusing not countries reporting that indicated prevention programmes just on individual programmes, but also on factors such as are available to the majority of those in need. Tis approach, developed in the United States, is based on the premise that a Brief interventions aim to prevent or delay substance use, reduction in the prevalence of health and behavioural reduce its intensity or prevent escalation into problem use. Current data indicate that brief interventions are not widely l Addressing vulnerability and risk implemented in Europe, with 3 countries reporting full and extensive provision of such interventions in schools, and 2 Selective prevention responses for vulnerable groups are reporting that level of provision in low-threshold services. At the local level, such approaches can involve low-cost, with the potential for delivery in multiple settings multiple services and stakeholders (e. Examples youth and police), and are common in the Nordic countries of brief interventions implemented in several countries are and Ireland, as well as parts of Spain and Italy. Tis form of referral, which also includes referral Drug treatment is the primary intervention utilised for by family members or friends, accounted for around half of individuals who experience problems with their drug use, those entering specialised drug treatment in Europe in including dependence, and ensuring good access to 2015. An additional 25 % of clients were referred by health appropriate treatment services is a key policy aim. In a number of countries, schemes the treatment journeys that clients take and adjusting are in place to divert drug ofenders away from the criminal services to better ft observed needs. Tis may involve a court order to attend treatment or a suspended sentence conditional on treatment; in some countries diversion is also possible at earlier stages of the criminal justice process. In 2015, cannabis clients were the most likely to be referred by the criminal justice system; in Hungary, around 80 % of cannabis treatment referrals came from this source. Client pathways through drug treatment are often characterised by the use of diferent services, multiple entries and varying lengths of stay. An insight into treatment journeys is provided by results from an analysis of specialised treatment data from 7 European countries in 2015. Of the 400 000 clients reported in treatment in these countries during that year, just under 20 % had entered treatment for the frst time in their life; around 30 % had re-entered treatment, having received treatment in an earlier year; and around half had been in continuous treatment for more than 1 year. Most of the clients in continuous treatment were males, in their late 30s, had been in treatment for more than 3 years and had problems related to opioid use, especially heroin. While many countries psychoactive medicines, including antidepressants, ofer treatment for people with cannabis problems within anxiolytics and mood stabilisers. To date, results have generic substance use programmes, around half have been inconsistent, and no efective pharmacological developed some cannabis-specifc treatment options. Although most treatment for this group takes place in community or Drug treatment: mainly provided in community outpatient settings, around one in fve people entering l settings specialist inpatient drug treatment services reported a primary cannabis-related problem. Opioid users psychosocial approaches; family-based interventions are represent the largest group undergoing specialised often used for adolescents and cognitive-behavioural treatment and consume the greatest share of available interventions for adults. Te available evidence supports treatment resources, mainly in the form of substitution the use of a combination of cognitive-behavioural therapy, treatment. Cannabis and cocaine users are the second motivational interviewing and contingency management and third largest groups entering these services approaches. Internet and digital-based interventions countries can be very large, however, with opioid users are increasingly employed to reach cannabis users, and accounting for more than 90 % of treatment entrants in studies to measure the efects of this type of interventions Estonia and less than 5 % in Hungary. Tis category includes general practitioners’ surgeries, which are important prescribers of opioid substitution treatment in some large countries such as Germany and France. Elsewhere, for example in Slovenia, mental healthcare centres may play a key role in outpatient treatment provision. Te relative importance of outpatient and communities (27 900) inpatient provision within national treatment systems Prisons varies greatly between countries. Internet-based interventions have the potential to extend the reach and geographical coverage of treatment programmes to people experiencing drug use problems who may not otherwise access specialist drug services. Te available evidence supports this approach, with positive outcomes found in respect to A comparison with current estimates of the number of treatment retention, illicit opioid use, reported risk high-risk opioid users in Europe would suggest that half behaviour, drug-related harms and mortality. However, these fndings An estimated 630 000 opioid users received substitution must be interpreted cautiously for methodological reasons. Te trend shows an increase Methadone is the most commonly prescribed opioid in clients up to a peak in 2010, followed by a 6 % decline to substitution drug, received by around two thirds (63 %) of 2015. A further 35 % of clients are treated in 12 countries, with the largest (decreases of more than with buprenorphine-based medications, which is the 25 %) reported by Spain, Hungary, the Netherlands and principal substitution drug in 8 countries (Figure 3. Tis decline may be explained by factors related Other substances, such as slow-release morphine or to demand or provision, including a falling population of diacetylmorphine (heroin), are more rarely prescribed, ageing, chronic opioid users or shifts in treatment goals in being received by an estimated 2 % of substitution clients some countries. In the 9 countries for which data community settings and continuity of care after prison are available, between 1 % and 26 % of all opioid users in release. Te availability of opioid substitution treatment in treatment receive interventions not involving opioid prisons is reported by 28 of the 30 countries monitored by substitution (Figure 3. Detoxifcation, individual and group counselling, and therapeutic communities or special inpatient wards are available in most countries. Many l Prisons: low availability of hepatitis C treatment European countries have established interagency partnerships between prison health services and providers Prisoners report higher lifetime rates of drug use and more in the community, in order to facilitate delivery of health harmful patterns of use (including injecting) than the education and treatment interventions in prison and to general population, making prisons an important setting ensure continuity of care upon prison entry and release. Many prisoners have complex healthcare needs, and assessment of drug use and drug-related problems is an important part of the health screening at prison entry in many countries. Te Hospital emergency data can provide an insight into acute provision of clean injecting equipment is less common, drug-related harms. Te 5 054 presentations Preparation for prison release, including social recorded by the project in 2015 had a median age of reintegration, is carried out in most countries. Nearly two information and the provision of naloxone upon prison thirds of presentations (65 %) involved the use of release. Half of the presentations for new psychoactive substances involved a synthetic cathinone and 14 % a synthetic cannabinoid. Te drugs involved in emergency presentations difered between sites, refecting local patterns of use. More than 50 deaths were reported, many of allow a national analysis of trends in acute drug which were attributed directly to these substances. In Spain, cocaine is involved in about half of the reported drug-related emergencies, and the trend is stabilising after a decline, while cannabis emergencies are continuing to increase. New psychoactive Methamphetamine-related emergency cases, recorded by sentinel centres in the Czech Republic, increased by more substances are causing than 50 % between 2014 and 2015. Fentanyls are exceptionally potent opioids which, although playing a small role in Europe’s drug market, pose a serious threat to individual and public health. In part this stems from the increased risk of severe and fatal poisonings in users — often manifesting as outbreaks — as fentanyls cause rapid and profound respiratory depression.

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Prescription drug abuse is present • Morphine (Kadian® quality alfuzosin 10mg prostate removal surgery, Avinza®) in 12% to 15% of elderly individuals who seek medical • Codeine (Tylenol® #2 buy alfuzosin 10mg prostate oncology specialists nj, 3 generic alfuzosin 10mg free shipping mens health zinc, 4) attention. In addition to the toll on individuals and • Oxycodone (OxyContin®, Percodan®, Percocet®) families, abuse places a heavy fnancial toll on health • Hydrocodone (Lortab®, Lorcet®, Vicodin®) care systems. Health problems related to substance • Propoxyphene (Darvon®) abuse cost Medicare $233 million dollars in 1989, • Fentanyl (Duragesic®) and probably account for much larger expenditures • Hydromorphone (Dilaudid®) today. Whereas youth are using prescription - Alprazolam (Xanax®) drugs to get high, party, or as a study aid, senior - Triazolam (Halcion®) citizens, the focus of this issue, are more inclined - Estazolam (ProSom®) towards inadvertent misuse. Abuse or misuse of prescription drugs is second only to alcohol abuse in Common stimulants include: this over 65 demographic. Primarily used include opiates, central nervous system depressants, 3 to treat anxiety and sleep disorders, there are two types and stimulants due to their addictive qualities. Opiates are very efective analgesics (pain narcolepsy and attention defcit hyperactivity disorder relievers). The most commonly known prescription as well as elevate blood pressure, heart rate, and opiates are Vicodin® and OxyContin®. Currently one in eight Americans consumer segment for legal drugs in the United States. More specifcally, elderly individuals use prescription The first wave of baby boomers will turn 60 over the drugs approximately three times as frequently as the next decade. The estimated annual expenditure people 65 and older than 14 and under in the United on prescription drugs by the elderly in the United States States. Of the current population, 83% of older adults, people age 60 and over, take prescription drugs. Older adult women take an average of fve prescription drugs at a time, for longer periods of time, than men. And studies show that half of those drugs are potentially addictive substances, like sedatives, making older females more susceptible to potential abuse issues. Contributing factors The life changes that occur as one reaches their twilight years are signifcant. Elderly patients can experience a mixture of social-emotional, physical, and functional changes that may encourage addiction. Physiological contributors include high rates of co-morbid illnesses, changes in metabolism (that afect drug potency), and shifting hormone levels, for example changes in melatonin levels resulting in altered sleep/wake cycles. Mental health concerns also arise, especially with those experiencing major health problems. Though not considered a normal part of aging, depression is a specifc concern that can initiate or exacerbate a decline in function and overall health. Physically, some seniors slow down and become compromised in their mobility and dexterity. If unable to engage socially or participate in activities-of-daily-living as they are accustomed to, seniors may turn to using medications that ease this reality or that appear to make life easier. Often, doctors prescribe “coping” drugs to help patients with anxiety, depression, or sleeplessness, many of which are addictive. Some factors to consider when examining this issue include: • The elderly are more likely to be prescribed several diferent medications at once and for a prolonged duration of time. Symptoms can be masked by normal or perceived signs of aging, the elderly may deny symptoms of abuse, and may be unaware of their misuse. This include the following: contrasts with the 56% increase in prescriptions written for non-controlled medications. As with other • Many of the symptoms of misuse and abuse populations, seniors who are using these medications mirror common signs of aging in general. Some of these continue use: perceptions include: (1) Prescription Fraud - This ranges from forging or altering prescriptions, to impersonating physicians over • Memory loss the phone, to producing counterfeit prescriptions. The individual then • Chronic boredom has these prescriptions flled at diferent pharmacies to avoid suspicion of illegal activity. Many elderly individuals are turning to not uncommon for a person to have multiple internet pharmacies for discount price prescription prescriptions for diferent conditions, without any drugs. Internet pharmacies are unregulated and can single prescriber knowing the entire set of drugs be unsafe, with some dispensing medication without being used. Therefore, healthcare providers are a prescription, doctor’s consultation, or even verifying not alerted to look for, and do not recognize signs the individual’s age. This includes awareness of problems prescription costs or just passing on something that associated with taking multiple drugs and their has worked well for them, family and friends knowingly potential interactions. Administration (2005) Provide information • Collaborate with existing senior services such as • Create and disseminate promotional materials In Home Support Services, Senior Centers, Meals on (make it available in large print) that specifcally Wheels, and City Parks and Recreation programs. Examples include prescription diaries that allow individuals to list the medications Enhance screening and brief intervention skills of they are taking, easy-to-read, comprehensive health care clinicians booklets on how to take prescription drugs • Clinicians can properly assess their patients including wisely, tips for keeping medications secure, and assessing the risk of abuse in an individual, proper a list of questions that elders should ask about diagnosis, and proper record keeping. Screening also can be • Encourage pharmacists to provide clear information performed if patients present specifc symptoms and advice about how to take medications properly associated with problem use of a medication. Also, encourage • Clinicians are in a unique position to implement pharmacists to be aware of fraud or diversion by brief intervention skills to identify prescription drug looking for false or altered prescription forms as well abuse when it exists and help patients recognize the as being aware of potential “doctor shopping. Form community coalitions Educate the elderly • Bring all of the players to the table, including • Create a consumer education program that local health care practitioners, community specifcally targets older adult concerns, including health systems, law enforcement personnel, an ongoing wellness discussion series and pharmaceutical companies, senior housing activities. They are an excellent source of help, especially for speakers, intervention strategies, and • Reinforce the importance of collaboration in all of materials. Electronic tracking and that involves pharmaceutical companies, reminder systems are also developed to evaluate pharmacies, and medical professionals. The Gatekeeper Program is a collaborative efort between community services (such as a local prescription drug misuse and abuse adult day care center or Adult Protective Services) among the elderly in their communities? The ofce then contacts the elderly in nonproft and governmental agencies in person, assesses his/her needs, and gets whatever California to help them better serve their older help is required from the appropriate health or clients. Screening determines the severity of substance use and identifes the appropriate Programs and Services level of intervention. It may also motivate and Treatment for Late Life Depression) is a program refer those identifed as needing more extensive in which a depression care manager (usually services to a specialist setting for assessment, a nurse, social worker or psychologist) works diagnosis, and appropriate treatment. This fosters communication between the 6 Conclusion Other Resources The use of prescription medications for non-medical Older Adults: Depression and Suicide Facts (2007). American Society on Aging and American Society of Consultant Pharmacist Foundation. Anyone with a prescription for medication should be informed on how to secure, count, and properly dispose of unused medication. Doctors and pharmacists can be trained on predictors of medication non-adherence, as well as “doctor shopping” and other forms of fraud. Any well-rounded efort will address the factors that drive all substance abuse: dose, route of administration, co-administration with other drugs, context of use, and expectations. Moreover, for the older adult population, addressing the factors related to willful and inadvertent misuse of prescription medication is a necessary part of prevention and early intervention.

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Filtration: A treatment process for removing particulate matter from water by passage through porous media Water Treatment Manual: Disinfection Floc: In drinking water treatment order alfuzosin 10mg man health 6 health, floc refers to the fine cloud of spongy particles that form in water to which a coagulant has been added purchase alfuzosin visa prostate cancer treatment drugs. Flocculation: A process to enhance agglomeration or collection of smaller floc particles into larger order alfuzosin 10mg without a prescription androgen hormone in pregnancy, more easily settleable particles through gentle stirring by hydraulic or mechanical means following chemical addition of aluminium or iron salts and polyelectrolytes. Hardness: Hardness in water, usually expressed in mg/l CaCo3 is the measure of the concentration of dissolved calcium and magnesium salts, particularly carbonates and bicarbonates. There is no health risk associated with hard water, however, it can be difficult to lather and can cause scaling problems in hot water systems Headloss: The head, pressure or energy lost by water flowing in a pipe, in a channel or through a tank as a result of turbulence caused by the velocity of the flowing water and the roughness of the pipe, channel walls or restrictions caused fittings. Water flowing in a pipe or channel loses head, pressure or energy as a result of friction losses. The head loss through a filter is due to friction losses caused by material building up on the surface or in the interstices of the filter media. When water containing these cysts is ingested by a new host, the protozoa cause a severe gastrointestinal illness called giardiasis. Granular The term refers to Activated Carbon: a) the highly porous adsorbent filter media which is produced by heating coal or wood in the absence of air prior to crushing the material into granulated form approximately 1mm in size b) the constituent element of a water treatment process by which treatment process water is passed through such media. Activated carbon is positively charged and therefore able to remove negative ions from the water such as chlorine and ozone and is recognised as an effective method of reducing dissolved organics and associated taste and odour problems in water by adsorption. Inactivation: The effect that the application of a disinfectant has in destroying the cellular structure of pathogenic micro-organisms or in disrupting their metabolism, biosynthesis or ability to grow/reproduce, thereby inhibiting their ability to infect a host and cause human illness or disease. Inorganic Materials: Chemical substances of mineral origin, such as sand, salt, iron. Such persons are more prone to more serious infections and/or complications than healthy people. Log inactivation: A mathematical measure of microorganisms inactivation consequent to the application of a particular dosage by a given disinfection process, expressed as the log of the relative number of live organisms to unviable organisms remaining after exposure to the disinfection process Percentage reduction of viable organisms is expressed as (2-x) [100-10 ]% where x is the log inactivation value One log activation means that 90% of the microorganisms are no longer viable. Log removal: The percentage of microorganisms physically removed by a given process. L: The Occupational Exposure Limit means the maximum permissible concentration, of a chemical agent in the air at the workplace to which workers may be exposed Oxidant: A substance that readily oxidizes (removes electrons from) something chemically. Common drinking water oxidants are chlorine, chlorine dioxide, ozone, and potassium permanganate. Pathogens: Microorganisms that can cause disease in humans, other organisms or animals and plants. They may be bacteria, viruses, or protozoa and are found in sewage, in runoff from animals, farms or rural areas populated with domestic and/or wild animals, and in water. Water Treatment Manual: Disinfection There are many types of microorganisms which do not cause disease. Mathematically, pH is the negative logarithm (base 10) of the hydrogen ion concentration, [H+]. The pH may range from 0 to 14, where 0 is most acidic, 14 most basic, and 7 neutral. Plug flow: The travel of water through a tank, pipe, or treatment process unit in such a fashion that the entire mass or volume is discharged at exactly the theoretical detention time of the unit. For chlorination byproducts) systems, precursors are constituents of natural organic matter, comprising suspended solids, turbidity, colour and dissolved organic carbon. In addition, for ozonation systems, the bromide ion (Br-) is a precursor material. Secondary The application of a chemical disinfectant at the end of a treatment Disinfection: system or at some appropriate point along the distribution network to maintain the disinfection residual throughout the system to consumers. Slow Sand A filter that consists of a bed of fine sand and relies on a biologically Filtration: active layer on top of the sand, called Schmutzdecke, to filter out particles. Surface water can be running (as in streams and rivers) or quiescent (as in lakes, reservoirs, impoundments and ponds). Tracer: A foreign substance (such a dye) mixed with or attached to a given substance for subsequent determination of the location or distribution of the foreign substance. Tracer study: A study using a substance that can readily be identified in water (such as a dye) to determine the distribution and rate of flow in a tank, pipe, ground water, or stream channel. Turbidimeter: An instrument for measuring and comparing the turbidity of liquids by passing light through them and determining how much light is reflected by the suspended particulate matter in the liquid. Water The phenomenon of oscillations in the pressure of water in a closed Hammer: conduit flowing full, which results from a too rapid acceleration or retardation of flow. Momentary pressures greatly in excess of the normal static or pumping pressure may be produced in a closed pipe from this phenomenon. Absence of characterisation of the raw water source Conduct catchment risk assessment and/or establish monitoring programme. Urban Waste Water discharge upstream with potential to cause microbial Ensure appropriate treatment and robust disinfection system in place contamination with appropriate monitors and alarms on key equipment. Storm water overflow upstream with potential to cause microbial contamination Ensure appropriate treatment and robust disinfection system in place with appropriate monitors and alarms on key equipment. On site systems/ septic tanks upstream with potential to cause microbial Ensure appropriate treatment and robust disinfection system in place contamination with appropriate monitors and alarms on key equipment. Presence of Cryptosporidium in raw water Liaison with stakeholders to prevent contamination of surface waters. Appropriate treatment in place for Cryptosporidium removal/inactivation and consider additional treatment if needed. Contamination Ensure appropriate treatment and robust disinfection system in place with appropriate monitors and alarms on key equipment. Water Treatment Manual: Disinfection Hazard Control Abattoirs - Organic and Microbial Contamination Liaison with stakeholder to prevent contamination of surface waters. Ensure appropriate treatment and robust disinfection system in place with appropriate monitors and alarms on key equipment. Wildlife - Organic and Microbial Contamination Consider additional fencing/security to prevent wildlife if possible. Recreational use causing microbial contamination Regulate or influence recreational use to prevent or reduce contamination. Forestry felling causing increased sedimentation of the raw water and Turbidity monitor at intake, ability to shut off intake if raw water beyond challenging disinfection acceptable limits. Catchment: Ground Water Supply Hazard Control Geology - swallow holes (surface water ingress) associated with raw water Turbidity monitoring to identify deterioration in quality, appropriate source treatment to deal with source water. Consider closing intake or switching to other sources if raw water quality deteriorates. Well head casing incomplete or borehole unsealed causing intrusion of surface Secure and maintain well head to prevent contamination. Well head not secured against livestock access causing microbial Protect well-head with appropriate cover. Water Treatment Manual: Disinfection Hazard Control contamination Infiltration gallery influenced by surface water causing microbial contamination Monitor source water. Land drains causing preferential pathway for pollution of shallow well source Re-route land drains.

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