Expected annual probability of infection: A flood-risk approach to waterborne infectious diseases.

This study introduces a new approach for the investigation of infections after an accidental ingestion of contaminated floodwater. The concept of Expected Annual Probability of Infection (EAPI) is introduced and implemented in an infection risk-model approach, by combining a Quantitative Microbial Risk Assessment (QMRA) with the four steps in flood risk assessment. Two groups and exposure paths are considered: adults wading in floodwater and small children swimming/playing in floodwater. The study area is located in Ghana, West Africa. Even though Ghana is one of the most urbanized countries in Africa it has significant problems with water resources management and public health. While cholera is classified as endemic in Accra, the natural and human-made characteristics of the capital makes it prone to flooding. The results of the EAPI approach show that on one hand the concentration of pathogens in floodwater, and thus the risk of infection, decreases with the increase of the flood magnitude. On the other hand, larger floods can spread the pathogens further from the point source, threatening populations previously not identified as at risk by small-scale floods. The concept of EAPI is demonstrated for cholera but it can be extended to other waterborne diseases and also different pathways of exposure, requiring minimal adaptations. For future applications, better estimation of EAPI key components and improvement points are discussed and recommendations given for all the assessment steps.