Wastewater 

is any water that has been adversely affected in quality

by anthropogenic influence. It comprises liquid waste discharged by domestic residences,
commercial properties, industry, and/or agriculture and can encompass a wide range of
potential contaminants and concentrations. In the most common usage, it refers to the
municipal wastewater that contains a broad spectrum of contaminants resulting from the
mixing of wastewaters from different sources.

Sewage is correctly the subset of wastewater that is contaminated with feces or urine, but is

often used to mean any waste water. "Sewage" includes domestic, municipal, or
industrial liquid waste products disposed of, usually via a pipe or sewer or similar structure,
sometimes in a cesspool emptier.

The physical infrastructure, including pipes, pumps, screens, channels etc. used to convey
sewage from its origin to the point of eventual treatment or disposal is termed sewerage.

In some urban areas, sewage is carried separately in sanitary sewers and runoff from streets
is carried in storm drains. Access to either of these is typically through a manhole. During high
precipitation periods a sanitary sewer overflow can occur, causing potential public
health andecological damage.

Sewage may drain directly into major watersheds with minimal or no treatment. When

untreated, sewage can have serious impacts on the quality of an environment and on the
health of people. Pathogens can cause a variety of illnesses. Some chemicals pose risks even
at very low concentrations and can remain a threat for long periods of time because
of bioaccumulation in animal or human tissue.

Disposal of wastewaters from an industrial plant is a difficult and costly problem. Most
petroleum refineries, chemical and petrochemical plants[2][3] have onsite facilities to treat
their wastewaters so that the pollutant concentrations in the treated wastewater comply
with the local and/or national regulations regarding disposal of wastewaters into
community treatment plants or into rivers, lakes or oceans. Other Industrial processes
that produce a lot of waste-waters such as paper and pulp production has created
environmental concern leading to development of processes to recycle water use within
plants before they have to be cleaned and disposed of.[4]

Sanitation is the hygienic means of promoting health through prevention of human

contact with the hazards of wastes. Hazards can be either physical, microbiological,
biological or chemical agents of disease. Wastes that can cause health problems are
human and animal feces, solid wastes, domestic wastewater (sewage, sullage,
greywater), industrial wastes, and agricultural wastes. Hygienic means of prevention
can be by using engineering solutions (e.g. sewerage and wastewater treatment),
simple technologies (e.g. latrines, septic tanks), or even by personal hygiene practices
(e.g. simplehandwashing with soap).

The standard sanitation technology in urban areas is the collection of wastewater in sewers,

its treatment in wastewater treatment plants for reuse or disposal in rivers, lakes or the sea.
Sewers are either combined with storm drains or separated from them as sanitary
sewers. Combined sewers are usually found in the central, older parts or urban areas.
Heavy rainfall and inadequate maintenance can lead to combined sewer overflows or sanitary
sewer overflows, i.e. more or less diluted raw sewage being discharged into the
environment. Industries often discharge wastewater into municipal sewers, which can
complicate wastewater treatment unless industries pre-treat their discharges. [4]

The high investment cost of conventional wastewater collection systems are difficult to afford
for many developing countries. Some countries have therefore promoted alternative
wastewater collection systems such as condominial sewerage, which uses smaller diameter
pipes at lower depth with different network layouts from conventional sewerage.

Wastewater treatment

For more details on this topic, see Sewage treatment.

Sewage treatment plant, Australia.

In developed countries treatment of municipal wastewater is now widespread, [5] but not yet
universal (for an overview of technologies see wastewater treatment). In developing
countries most wastewater is still discharged untreated into the environment. For example, in
Latin America only about 15% of collected sewerage is being treated 

Wastewater treatment

For more details on this topic, see Sewage treatment.

Sewage treatment plant, Australia.

In developed countries treatment of municipal wastewater is now widespread, [5] but not yet
universal (for an overview of technologies see wastewater treatment). In developing
countries most wastewater is still discharged untreated into the environment. For example, in
Latin America only about 15% of collected sewerage is being treated 

The importance of waste isolation lies in an effort to prevent water and sanitation related

diseases, which afflicts both developed countries as well as developing countries to
differing degrees. It is estimated that up to 5 million people die each year from
preventable water-borne disease,[6] as a result of inadequate sanitation and hygiene
practices. The affects of sanitation have also had a large impact on society. Published
in Griffins Public Sanitation proven studies show that higher sanitation produces more
attractiveness.

Global access to improved sanitation

The Joint Monitoring Program for water and sanitation of WHO and UNICEF has defined
improved sanitation as

connection to a public sewer

connection to a septic system

pour-flush latrine

simple pit latrine

ventilated improved pit latrine [7]

According to that definition, 62% of the world's population has access to improved sanitation in
2008, up 8% since 1990. [1] Only slightly more than half of them or 31% of the world population
lived in houses connected to a sewer. Overall, 2.5 billion people lack access to improved
sanitation and thus must resort to open defecation or other unsanitary forms of defecation,
such as public latrines or open pit latrines.[8] This includes 1.2 billion people who have access to
no facilities at all.[9] This outcome presents substantial public health risks as the waste could
contaminate drinking water and cause life threatening forms of diarrhea to infants. Improved
sanitation, including hand washing and water purification, could save the lives of 1.5 million
children who suffer from diarrheal diseases each year.[9]

In developed countries, where less than 20% of the world population lives, 99% of the
population has access to improved sanitation and 81% were connected to sewers.

A sanitary sewer (also called a foul sewer) is a separate underground carriage system

specifically for transporting sewage from houses and commercial buildings to treatment or
disposal. Sanitary sewers serving industrial areas also carry industrial wastewater. The 'system
of sewers' is called sewerage.

Sanitary sewers are operated separately and independently of storm drains, which carry
the runoff of rain and other water which wash into city streets.[1]:Ch.I [2] Sewers carrying both
sewage and stormwater together are called combined sewers.

Dieses

Diarrhea (from the Greek διάρροια meaning "flowing through"[2]), also

spelled diarrhoea, is the condition of having three or more loose or liquid bowel
movements per day.[3] It is a common cause of death in developing countries and the
second most common cause of infant deaths worldwide. The loss offluids through
diarrhea can cause dehydration and electrolyte imbalances. In 2009 diarrhea was
estimated to have caused 1.1 million deaths in people aged 5 and over[4] and 1.5 million
deaths in children under the age of 5.[1] Oral rehydration salts and zinc tablets are the
treatment of choice and have been estimated to have saved 50 million children in the
past 25 years.[1]

Cholera is an infection of the small intestine that is caused by the bacterium Vibrio

cholerae. The main symptoms are profuse watery diarrhea andvomiting. Transmission
is primarily through consuming contaminated drinking water or food. The severity of the
diarrhea and vomiting can lead to rapiddehydration and electrolyte imbalance. Primary
treatment is with oral rehydration solution and if these are not tolerated, intravenous
fluids. Antibiotics are beneficial in those with severe disease. Worldwide it affects 3-5
million people and causes 100,000-130,000 deaths a year as of 2010. Cholera was one
of the earliest infections to be studied by epidemiological methods.[cit
Signs and symptoms

A person with severe dehydration due to cholera. Note the sunken eyes and decreased skin
turgor which produces wrinkled hands

The primary symptoms of cholera are profuse painless diarrhea and vomiting of clear fluid.

[1]
 These symptoms usually start suddenly, one to five days after ingestion of the bacteria. [1] The
diarrhea is frequently described as "rice water" in nature and may have a fishy odor. [1] An
untreated person with cholera may produce 10-20 liters of diarrhea a day. [1] For every
symptomatic person there are 3 to 100 people who get the infection but remain asymptomatic.
[2]

If the severe diarrhea and vomiting are not aggressively treated it can, within hours, result
in dehydration and electrolyte imbalances.[1] The typical symptoms of dehydration include
low blood pressure, poor skin turgor (wrinkled hands), sunken eyes, and a rapid pulse .[1]

[edit]Cause

Main article: Vibrio cholerae

Drawing of Death bringing the cholera, inLe Petit Journal

Cholera is caused by eating contaminated food. A brief summary of the March 2010 position
paper |format=PDF |work=World Health Organization|accessdate=}}</ref> Transmission is
primarily due to the fecal contamination of food and water due to poor sanitation.[3] This
bacterium can, however, live naturally in aquatic environments. [4]

[edit]Susceptibility

About one hundred million bacteria must typically be ingested to cause cholera in a normal

healthy adult.[1] This dose, however, is less in those with lowergastric acidity (for instance
those using proton pump inhibitors).[1] Children are also more susceptible with two to four
year olds having the highest rates of infection.[1]

It has been said that cystic fibrosis genetic mutation in humans has maintained a selective

advantage: heterozygous carriers of the mutation (who are thus not affected by cystic fibrosis)
are more resistant to V. cholerae infections.[5] In this model, the genetic deficiency in the cystic
fibrosis transmembrane conductance regulator channel proteins interferes with bacteria
binding to the gastrointestinal epithelium, thus reducing the effects of an infection.

Individuals' susceptibility to cholera is affected by their blood type, with those with type O

blood being the most susceptible.[1][6]

[edit]Transmission
Cholera is typically transmitted by either contaminated food or water. In the developed world,
seafood is the usual cause, while in the developing world it is more often water. [1] Cholera has
been found in only two other animal populations: shellfish and plankton.[1]

People infected with cholera often have diarrhea, and if this highly liquid stool, colloquially
referred to as "rice-water," contaminates water used by others, disease transmission may
occur.[7] The source of the contamination is typically other cholera sufferers when their
untreated diarrheal discharge is allowed to get into waterways or into groundwater or drinking
water supplies. Drinking any infected water and eating any foods washed in the water, as well
as shellfishliving in the affected waterway, can cause a person to contract an infection.
Cholera is rarely spread directly from person to person. Both toxic and nontoxic strains exist.
Nontoxic strains can acquire toxicity through a lysogenic bacteriophage.[8] Coastal cholera
outbreaks typically follow zooplankton blooms, thus making cholera a zoonotic disease.

[edit]

Typhoid fever, also known as typhoid,[1] is a common worldwide illness, transmitted by the
ingestion of food or water contaminated with the feces of an infected person, which contain
the bacterium Salmonella enterica enterica, serovar Typhi.[2][3] The bacteria then perforate
through the intestinal wall and are phagocytosed by macrophages. The organism is a Gram-
negative short bacillus that is motile due to its peritrichous flagella. The bacterium grows best
at 37°C / 98.6°F – human body temperature.

This fever received various names, such as gastric fever, abdominal typhus, infantile remittant
fever, slow fever, nervous fever, pythogenic fever, etc. The name of "typhoid" was given
by Louis in 1829, as a derivative from typhus.

The impact of this disease falls sharply with the application of modern sanitation techniques.

yphoid fever is characterized by a slowly progressive fever as high as 40 °C (104 °F), profuse

sweating and gastroenteritis. Less commonly, a rash of flat, rose-colored spots may appear.[4]

Classically, the course of untreated typhoid fever is divided into four individual stages, each
lasting approximately one week. In the first week, there is a slowly rising temperature with
relativebradycardia, malaise, headache and cough. A bloody nose (epistaxis) is seen in a quarter
of cases and abdominal pain is also possible. There is leukopenia, a decrease in the number of
circulating white blood cells, with eosinopenia and relative lymphocytosis, a positive diazo
reaction and blood cultures are positive for Salmonella typhi or paratyphi. The classic Widal
test is negative in the first week..
In the second week of the infection, the patient lies prostrate with high fever in plateau around
40 °C (104 °F) and bradycardia (sphygmothermic dissociation), classically with a dicrotic
pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium gives
to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and
abdomen in around a third of patients. There are rhonchi in lung bases. The abdomen is
distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea
can occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable
to pea soup. However, constipation is also frequent. The spleen and liver are enlarged
(hepatosplenomegaly) and tender, and there is elevation of liver transaminases.
The Widal reaction is strongly positive with antiO and antiH antibodies. Blood cultures are
sometimes still positive at this stage. (The major symptom of this fever is the feverusually rises
in the afternoon up to the first and second week.)

In the third week of typhoid fever, a number of complications can occur:

Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious
but is usually not fatal.

Intestinal perforation in the distal ileum: this is a very serious complication and is frequently
fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in.

Encephalitis

neuropsychiatric symptoms (described as "muttering delirium" or "coma vigil"), with picking at

bedclothes or imaginary objects.

Metastatic abscesses, cholecystitis, endocarditis and osteitis

The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the
patient is delirious (typhoid state). By the end of third week the fever has started reducing this
(defervescence). This carries on into the fourth and final week.

[edit]

Meningitis is inflammation of the protective membranes covering the brain and spinal cord,

known collectively as the meninges.[1] The inflammation may be caused by infection
with viruses, bacteria, or other microorganisms, and less commonly by certain drugs.
[2]
 Meningitis can be life-threatening because of the inflammation's proximity to the brain and
spinal cord; therefore the condition is classified as a medical emergency.[1][3]

The most common symptoms of meningitis are headache and neck stiffness associated

with fever, confusion or altered consciousness, vomiting, and an inability to tolerate light
(photophobia) or loud noises (phonophobia). Sometimes, especially in small children,
only nonspecific symptoms may be present, such as irritability and drowsiness. If a rash is
present, it may indicate a particular cause of meningitis; for instance, meningitis caused by
meningococcal bacteria may be accompanied by a characteristic rash.[1][4]

A lumbar puncture may be used to diagnose or exclude meningitis. This involves inserting a

needle into the spinal canal to extract a sample ofcerebrospinal fluid (CSF), the fluid that
envelops the brain and spinal cord. The CSF is then examined in a medical laboratory. [3] The
usual treatment for meningitis is the prompt application of antibiotics and sometimes antiviral
drugs. In some situations, corticosteroid drugs can also be used to prevent complications from
overactive inflammation.[3][4] Meningitis can lead to serious long-term consequences such
as deafness, epilepsy, hydrocephalus andcognitive deficits, especially if not treated quickly.
[1][4]
 Some forms of meningitis (such as those associated with meningococci, Haemophilus
influenzaetype B, pneumococci or mumps virus infections) may be prevented
by immunization.[1

Clinical features

In adults, a severe headache is the most common symptom of meningitis – occurring in almost 90% of cases of bacterial

meningitis, followed by nuchal rigidity (inability to flex the neck forward passively due to increased neck muscle tone and

stiffness).[5] The classic triad of diagnostic signs consists of nuchal rigidity, sudden high fever, and altered mental status;

however, all three features are present in only 44–46% of all cases of bacterial meningitis.[5][6] If none of the three signs is

present, meningitis is extremely unlikely.[6] Other signs commonly associated with meningitis

includephotophobia (intolerance to bright light) and phonophobia (intolerance to loud noises). Small children often do not

exhibit the aforementioned symptoms, and may only be irritable and looking unwell.[1]In infants up to 6 months of age,

bulging of the fontanelle (the soft spot on top of a baby's head) may be present. Other features that might distinguish

meningitis from less severe illnesses in young children are leg pain, cold extremities, and an abnormal skin color.[7]

Nuchal rigidity occurs in 70% of adult cases of bacterial meningitis.[6] Other signs of meningism include the presence of

positive Kernig's sign or Brudzinski's sign. Kernig's sign is assessed with the patient lying supine, with the hip and knee

flexed to 90 degrees. In a patient with a positive Kernig's sign, pain limits passive extension of the knee. A positive

Brudzinski's sign occurs when flexion of the neck causes involuntary flexion of the knee and hip. Although Kernig's and

Brudzinski's signs are both commonly used to screen for meningitis, the sensitivity of these tests is limited.[6][8] They do,

however, have very good specificity for meningitis: the signs rarely occur in other diseases.[6] Another test, known as the "jolt

accentuation maneuver" helps determine whether meningitis is present in patients reporting fever and headache. The

patient is told to rapidly rotate his or her head horizontally; if this does not make the headache worse, meningitis is unlikely.[6]

Meningitis caused by the bacterium Neisseria meningitidis (known as "meningococcal meningitis") can be differentiated from

meningitis with other causes by a rapidly spreading petechial rash which may precede other symptoms.[7] The rash consists

of numerous small, irregular purple or red spots ("petechiae") on the trunk, lower extremities, mucous membranes,
conjuctiva, and (occasionally) the palms of the hands or soles of the feet. The rash is typically non-blanching: the redness

does not disappear when pressed with a finger or a glass tumbler. Although this rash is not necessarily present in

meningococcal meningitis, it is relatively specific for the disease; it does, however, occasionally occur in meningitis due to

other bacteria.[1] Other clues as to the nature of the cause of meningitis may be the skin signs of hand, foot and mouth

disease and genital herpes, both of which are associated with various forms of viral meningitis.[9]

[edit]Early complications

A severe case of meningococcal meningitis in which the petechial rash progressed to gangrene and requiredamputation of all limbs. The

patient,Charlotte Cleverley-Bisman, survived the disease and became a poster child for a meningitis vaccination campaign in New Zealand.

People with meningitis may develop additional problems in the early stages of their illness. These may require specific

treatment, and sometimes indicate severe illness or worse prognosis. The infection may trigger sepsis, a systemic

inflammatory response syndrome of falling blood pressure, fast heart rate, high or abnormally low temperature and rapid

breathing. Very low blood pressure may occur early, especially but not exclusively in meningococcal illness; this may lead to

insufficient blood supply to other organs.[1] Disseminated intravascular coagulation, the excessive activation of blood clotting,

may cause both the obstruction of blood flow to organs and a paradoxical increase of bleeding risk. In meningococcal

disease, gangrene of limbs can occur.[1] Severe meningococcal and pneumococcal infections may result in hemorrhaging of

the adrenal glands, leading to Waterhouse-Friderichsen syndrome, which is often lethal.[10]

The brain tissue may swell, with increasing pressure inside the skull and a risk of swollen brain tissue causing herniation.

This may be noticed by a decreasinglevel of consciousness, loss of the pupillary light reflex, and abnormal posturing.
[4]
 Inflammation of the brain tissue may also obstruct the normal flow of CSF around the brain (hydrocephalus).
[4]
 Seizures may occur for various reasons; in children, seizures are common in the early stages of meningitis (30% of cases)

and do not necessarily indicate an underlying cause.[3] Seizures may result from increased pressure and from areas of

inflammation in the brain tissue.[4] Focal seizures (seizures that involve one limb or part of the body), persistent seizures,

late-onset seizures and those that are difficult to control with medication are indicators of a poorer long-term outcome.[1]

The inflammation of the meninges may lead to abnormalities of the cranial nerves, a group of nerves arising from the brain

stem that supply the head and neck area and control eye movement, facial muscles and hearing, among other functions.[1]
[6]
 Visual symptoms and hearing loss may persist after an episode of meningitis (see below).[1] Inflammation of the brain

(encephalitis) or its blood vessels (cerebral vasculitis), as well as the formation of blood clots in the veins (cerebral venous
thrombosis), may all lead to weakness, loss of sensation, or abnormal movement or function of the part of the body supplied

by the affected area in the brain.[1][4]