Category Archives: Water

USA – Waterborne Disease Outbreak Investigation Toolkit

CDC

The Waterborne Disease Outbreak Investigation Toolkit is a guide to assist state and local health departments in conducting waterborne disease outbreak investigations. CDC developed this toolkit to help partners address the unique challenges they face when investigating waterborne disease outbreaks. Because of the numerous ways in which water impacts every person’s daily lives, timely detection, response, and control of these outbreaks is crucial to protect public health.

Using experiences of epidemiologists at the state and local levels, this toolkit describes best practices in preparing for, identifying, and remediating a waterborne disease outbreak.

For outbreaks related to recreational water, visit CDC’s Recreational Water Illness Outbreak Response Tools page.

CDC is available to assist local, state, territorial, and tribal health departments—as well other countries’ ministries of health—with investigating and controlling waterborne disease outbreaks.

How to Use the Toolkit

All of the toolkit content can be found by navigating through this website. It is also available as a PDF document pdf icon[PDF – 36 pages].

Research – Giardiasis Outbreaks — United States, 2012–2017

CDC

CDC Giardia2

Summary

What is already known about this topic?

Giardiasis is a diarrheal disease caused by the parasite Giardia duodenalis, the most common cause of intestinal parasite infections in the United States.

What is added by this report?

During 2012–2017, public health officials from 26 states reported 111 giardiasis outbreaks involving 760 cases. Leading causes of outbreaks were waterborne and person-to-person exposures. Private residences and child care facilities were the most common settings of giardiasis outbreaks across all transmission modes.

What are the implications for public health practice?

To prevent and control giardiasis outbreaks, CDC recommends prompt diagnosis, maintaining good hand hygiene, cleaning and disinfecting home environments and child care facilities, and monitoring water quality in private well

Giardiasis is a diarrheal disease caused by the parasite Giardia duodenalis, the most common cause of intestinal parasite infections in the United States. Transmission occurs when Giardia cysts spread from feces to water, food, surfaces, or skin and are then ingested. Illness is characterized by gastrointestinal symptoms, including diarrhea, abdominal cramps, greasy stools, bloating or gas, nausea, vomiting, weight loss, and dehydration. Approximately 50% of infections are asymptomatic (1,2). Most symptomatic Giardia infections are self-limited in duration; however, some persons might experience a reoccurrence of symptoms or develop long-term complications (3). During 2012–2017, public health officials from 26 states reported 111 giardiasis outbreaks (760 cases) to the National Outbreak Reporting System (NORS). Three main modes of transmission for these outbreaks were identified: water exposure in 29 (26%) outbreaks, person-to-person contact in 28 (25%) outbreaks, and contaminated food in six (5%) outbreaks. A single transmission mode could not be determined in 48 (43%) of the outbreaks. Private residences and child care facilities were the most common settings of outbreaks for all the transmission modes combined. To prevent and control giardiasis outbreaks, CDC recommends prompt diagnosis, maintaining good hand hygiene, cleaning and disinfecting home environments and child care facilities, and monitoring water quality in private wells.

A giardiasis outbreak is defined as the occurrence of two or more cases of illness epidemiologically linked to a common exposure (1). Health department officials from across the United States (state, local, and District of Columbia), U.S. territories,* and freely associated states voluntarily report outbreaks to NORS. This study included giardiasis outbreak reports submitted to NORS by December 30, 2019 and data reported during 2012–2017 (the year of the earliest case illness onset date through the most recent year for which data were available). NORS data summarized in this study include primary case counts, hospitalizations, and deaths; transmission mode; exposures and settings; and earliest onset date. Negative binomial regression analysis was conducted to assess for annual trends in outbreak counts using SAS (version 9.4; SAS Institute). This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.§

During 2012–2017, public health officials from 26 states reported 111 giardiasis outbreaks with 760 primary cases, 28 hospitalizations, 48 emergency department visits, and no deaths. Among the 703 cases with available data, 370 (53%) persons were male and 333 (47%) persons were female. Pennsylvania reported the largest number of outbreaks with 44 (40%), followed by Minnesota with 11 (10%); no other state reported >10 outbreaks (Figure 1). There was no significant trend in giardiasis outbreaks by year (χ2 = 0.67, p = 0.98) (Figure 2).

Among 29 (26%) waterborne outbreaks (370 cases), exposure sources included tap water systems (e.g., municipal systems or private wells) in nine outbreaks, outdoor freshwater consumption in seven outbreaks, treated recreational water in five outbreaks, untreated recreational water in four outbreaks, and “other” in four outbreaks (Table). Reported settings for waterborne outbreaks included 12 (41%) outdoor areas (e.g., parks and forests) five (17%) private residences, four (14%) camps or cabins, three (10%) community/municipality settings, three (10%) unknown, and two (7%) other settings. Person-to-person transmission was the primary mode identified in 28 (25%) outbreaks, resulting in 129 cases. The primary exposure settings for these outbreaks were 14 (50%) private residences and 12 (43%) child care facilities (Table). Among the 14 settings in private homes, nine (64%) were in households with children aged ≤5 years; two (14%) were in homes with only adults. Among the six (5%) foodborne outbreaks, all foods associated with the five known food exposures were eaten raw or with minimal or no processing. No outbreaks were attributed to animal contact or environmental contamination other than food and water (i.e., contact with objects or surfaces with Giardia). Among all 111 outbreaks, 48 (43%) had an indeterminate or unknown transmission mode, meaning that there was insufficient evidence to implicate one specific primary mode of transmission; 33 (69%) of these outbreaks occurred in private residences (Table).

USA – NJDOH Investigates Legionnaires’ Cluster in Union County

NBC

Legionella A

The New Jersey Department of Health (NJDOH) is investigating a cluster of Legionnaires’ disease — a bacteria-triggered form of pneumonia — in Union County in which at least 14 cases, including one death, were confirmed.

The cases were reported to the state’s Department of Health between Feb. 3 and Feb. 26, according to officials.

Health officials are working with the local health departments in Union County to investigate this cluster. The individual who died was a male resident of Union County in his late 60s.

Taiwan – CDC issues Norovirus warning after Taiwan sees surge in cases

Taiwan News

Food Borne Illness - Norovirus -CDC Photo

The health authorities are sounding the alarm over norovirus-induced gastroenteritis, with cases soaring over the past week.

Taiwan recorded over 138,000 cases of diarrhea between Feb. 21 and 27, reflecting an uptick in stomach illnesses following the Lunar New Year. Over the past four weeks, 87 diarrhea clusters have been reported nationwide, and 97 percent of the 58 cases where pathogens were identified pointed to norovirus as the culprit, according to the Taiwan Centers for Disease Control (CDC).

Members of the public are urged to improve their hygiene, as the virus is transmitted via the fecal-oral route, which involves contaminated food or water or contact with infected persons.

USA – Ongoing lead, Legionella water issues in schools

Downtown Publications

CDC legionella

As students return to full in-person instruction, many Birmingham Public Schools continue to be plagued by locations where legionella has been found, as well as lead and copper, with remediation continuing in all affected buildings.

Reports have come in from Greenfield, Quarton, Beverly, Pierce, Harlan and West Maple elementary schools, Berkshire Middle School, and Seaholm and Grove high schools, indicating that while there have been improvements in the water quality at the schools since they were last tested last fall, continued remediation is still needed to eliminate all legionella from school plumbing. There have not been updates Derby Middle Schools or Birmingham Covington School.

According to communications from the school, “BPS is focused on the remediation of legionella while providing a lead-free source of drinking water for all staff and students. BPS will shift to cold water flushes to reduce copper and lead in the system in the coming weeks. All individuals should use water from home or bottled water until water filter stations are enabled again.”

At Groves, while legionella was found at more than 220 locations at the school in the first round of testing, following remediation and retesting, there are currently 79 locations were it was found.

Research – Hepatitis A outbreak with the concurrence of Salmonella Typhi and Salmonella Poona infection in children of urban Vellore, south India – 2019

IJID Online

Background: Outbreaks of Hepatitis A virus (HAV) infection continue to be reported from India, that have transitioned from hyper-to-intermediate endemicity. Hepatitis A and Salmonella sp. share similar routes of transmission and may co-infect individuals at risk. We report here an outbreak of hepatitis A with concomitant Salmonellosis from an urban settlement of Vellore in south India between July and August 2019.

Our findings highlight that Hepatitis A infection can present as sporadic outbreaks in communities with sub-standard water and sewage systems, along with the co-infection of other enteric infections such as invasive Salmonellosis. Thus, population-based surveillance for Hepatitis A is required in India, to identify populations and geographical regions at risk, and thereby potentially plan implementation strategies for Hepatitis A vaccination.

India – One dead and 14 fall ill in Andhra village, food poisoning suspected

The News Minute

Around 15 persons in Ternekal village of Andhra’s Kurnool district have fallen sick with nausea, vomiting and diarrhea in the past four days, causing anxiety among the residents. One of the affected persons, a 62-year-old man named Venkatesh, died while undergoing treatment at Kurnool GGH (Government General Hospital) on Tuesday. Authorities have said that the illness could have been caused by consumption of stale food. Water samples have been sent to a regional lab to test for water contamination.

Research – Secret to how cholera adapts to temperature revealed

Science Daily

Food Illness

Scientists have discovered an essential protein in cholera-causing bacteria that allows them to adapt to changes in temperature, according to a study published today in eLife.

The protein, BipA, is conserved across bacterial species, which suggests it could hold the key to how other types of bacteria change their biology and growth to survive at suboptimal temperatures.

Vibrio cholerae (V. cholerae) is the bacteria responsible for the severe diarrheal disease cholera. As with other species, V. cholerae forms biofilms — communities of bacteria enclosed in a structure made up of sugars and proteins — to protect against predators and stress conditions. V. cholerae forms these biofilms both in their aquatic environment and in the human intestine. There is evidence to suggest that biofilm formation is crucial to V. cholerae’s ability to colonise in the intestine and might enhance its infectivity.

“V. cholerae experiences a wide range of temperatures, and adapting to them is not only important for survival in the environment but also for the infection process,” explains lead author Teresa del Peso Santos, a postdoctoral researcher at the Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, Sweden. “We know that at 37 degrees Celsius, V. cholerae grows as rough colonies that form a biofilm. However, at lower temperatures these colonies are completely smooth. We wanted to understand how it does this.”

The researchers screened the microbes for genes known to be linked with biofilm formation. They found a marked increase in the expression of biofilm-related genes in colonies grown at 37C compared with 22C.

To find out how these biofilm genes are controlled at lower temperatures, they generated random mutations in V. cholerae and then identified which mutants developed rough instead of smooth colonies at 22C. They then isolated the colonies to determine which genes are essential for switching off biofilm genes at low temperatures.

The most common gene they found is associated with a protein called BipA. As anticipated, when they intentionally deleted BipA from V. cholerae, the resulting microbes formed rough colonies typical of biofilms rather than smooth colonies. This confirmed BipA’s role in controlling biofilm formation at lower temperatures.

To explore how BipA achieves this, the researchers compared the proteins produced by normal V. cholerae with those produced by microbes lacking BipA, at 22 and 37 degrees Celsius. They found that BipA alters the levels of more than 300 proteins in V. cholerae grown at suboptimal temperatures, increasing the levels of 250 proteins including virtually all known biofilm-related proteins. They also showed that at 37 degrees Celsius, BipA adopts a conformation that may make it more likely to be degraded. In BipA’s absence, the production of key biofilm regulatory proteins increases, leading to the expression of genes responsible for biofilm formation.

These results provide new insights into how V. cholerae adapts to temperature and will help understand — and ideally prevent — its survival in different environments and transmission into humans.

“We have shown that BipA is critical for temperature-dependent changes in the production of biofilm components and alters colony shape in some V. cholerae strains,” concludes senior author Felipe Cava, Associate Professor at the Department of Molecular Biology, and MIMS Group Leader and Wallenberg Academy Fellow, Umeå University. “Future research will address the effect of temperature- and BipA-dependent regulation on V. cholerae during host infection and the consequences for cholera transmission and outbreaks.”

Australia – Legionnaires’ disease cases up in Sydney

Outbreak News Today

CDC legionella

NSW Health is reporting an increase in Legionnaires’ disease cases in the Greater Sydney area in December and January.

Seventeen cases of Legionnaires’ disease were notified across Sydney and in the Illawarra in January.

Health officials has not identified a specific source to date and reminds building owners to ensure cooling towers are properly maintained.

“Public Health Unit staff investigate each case of Legionnaire’s disease and no specific source has been identified,” Director of Health Protection Dr Richard Broome said.

Greece – Evidence for waterborne origin of an extended mixed gastroenteritis outbreak in a town in Northern Greece, 2019

Cambridge Core

We investigated a large gastroenteritis outbreak that occurred in Northern Greece in 2019. A case was defined as anyone presenting with diarrhoea and/or vomiting from 24/01/2019 to 04/02/2019. We conducted a case-control study (CCS) using random selection of participants >16 years of age, residents of town X, who visited the health care centre between 25-28/01/2019.

Moreover, we conducted a retrospective cohort study (CS) at the four elementary schools of the town. We collected clinical and water samples and the water supply system was inspected. In total, we recorded 638 cases (53% female; median age was 44 years (range 0-93)). Forty-eight cases and 52 controls participated in the CCS and 236 students in the CS. Both CCS and CS indicated tap water as the most likely source (OR=10, 95% CI, 2.09-93.4, explaining 95.7% of cases; RR= 2.22, 95% CI, 1.42-3.46, respectively).

More than one pathogen were detected from stool samples of 6 of the 11 cases tested (norovirus, Campylobacter jejuni, EHEC and EPEC). Water samples, collected after ad-hoc chlorination, tested negative. Technical failures of the water tanks’ status were identified. Our results suggested a waterborne outbreak. We recommended regular monitoring of the water supply system and immediate repair of technical failures.