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Management of a Cryptosporidiosis Outbreak in the South East – Lessons Learned. Dr BethAnn Roch Dr Ann Marie O’Byrne Consultants in Public Health Medicine, HSE-SE On behalf of the Incident Response Team. Outline of Presentation. Description of outbreak Results Action taken Discussion - PowerPoint PPT Presentation
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1
Management of a Cryptosporidiosis Outbreak in the South East –
Lessons Learned
Dr BethAnn Roch
Dr Ann Marie O’Byrne
Consultants in Public Health Medicine, HSE-SE
On behalf of the Incident Response Team
2
Outline of Presentation
• Description of outbreak
• Results
• Action taken
• Discussion – Issues arising– Lessons learned
3
4
Problem Identification
• Trigger: 4 cases of cryptosporidiosis in a 3 week period in Carlow
• Notifiable disease in ROI since Jan 2004
Immediate actions• Enhanced surveillance• Contact PEHO County Council• Contact GPs advise vulnerable i.c. to boil water
AIG to send stool samples• Meeting convened between HSE-SE and County
Council
5
Epidemic Curve
Epi Curve for all cases
543
Cases 21
24-Jan
31-Jan
7-Feb
14-Feb
21-Feb
28-Feb
7-Mar
14-Mar
21-Mar
28-Mar
4-Apr
11-Apr
18-Apr
25-Apr
2-May
9-May
Onset (Week Commencing)
6
Descriptive Epidemiology• 31 laboratory confirmed cryptosporidiosis
• 18 females, 13 males: 8 cases hospitalised
Age Distribution of Cases
8
3 2
14
3
10
5
10
15
20
25
0-5 6-20 21-40 41+Age Groups
Nu
mb
er o
f C
ases
Female
Male
7
Geographical Distribution of
Cases
8
• Other risk factors– crèche contacts (8)– swimming pool (5)– private wells (9)– animals (14)– travel (3)
• 11 had no RF other than town water
Enhanced Surveillance
9
• Water results– Cryptosporidium 0.04/10L
– Giardia 0.02/10L
– Microbiology clear
• Faecal results– 31 laboratory confirmed cases
– 7 samples sent for genotyping: C. hominis
Results
10
• Regular meetings of IRT
• Swimming pool sampling and advice• Private wells sampled• Crèche visits and advice
• Council water measures – Water sampling– Risk assessments– Boil notice– Programme of works to minimise risk
Actions
11
Notification of cases, onset of illness and actions taken
0
5
10
15
20
25
30
35
40
17-J
an
24-J
an
31-J
an
7-F
eb
14-F
eb
21-F
eb
28-F
eb
7-M
ar
14-M
ar
21-M
ar
28-M
ar
4-A
pr
11-A
pr
18-A
pr
25-A
pr
2-M
ay
9-M
ay
16-M
ay
23-M
ay
30-M
ay
6-Ju
n
Week Commencing
Nu
mb
er o
f ca
ses
by
onse
t of
illn
ess
0
5
10
15
20
25
30
35
40
Cu
mu
lati
ve n
otif
icat
ion
of
case
s
Date of Onset Date of Notification
Boil water advice period 14/04/05 - 24/05/05
Sion Cross output reduced22/3/05 - 26/03/05
12
Issues arising
• Water
• Advice to vulnerable populations
• Communication
13
Cryptosporidium species
• Faecal– C. hominis
• Water– C. parvum– C. andersoni– C. muris
• Implications – reassurance?– Intermittent excretion, small dose infective dose– Immunocompromised– Evidence of breakthrough
14
An ‘acceptable’ level• Sampling
– Volume 500-1000L– Grab/continuous– 2 filters/3 labs
• Standards– UK– NI and Scotland
• Types identified– Virulence of C hominis
• Nature of source• Decision – 0.05 oocysts/10L
15
0.0
0.1
0.2
0.3
0.4
0.52-
Mar
12-M
ar
22-M
ar
1-A
pr
11-A
pr
21-A
pr
1-M
ay
11-M
ay
21-M
ay
31-M
ay
10-J
un
20-J
un
Date
No.
of
occy
sts
per
10
LBoil water advice period
14/04/05 - 24/05/05
Cryptosporidium
16 Source: Carlow County Council
0
2
4
6
8
10
12
14
16
18
20
20-Sep-04 9-Nov-04 29-Dec-04 17-Feb-05 8-Apr-05 28-May-05 17-J ul-05
Clostridium Perfringens No./100ml
Clostridium perfringens
17
C. perfringens and Cryptosporidium
0
2
4
6
8
10
12
14
16
18
20
Date
Clo
stri
diu
m p
erfr
ing
ens
/100
ml
0
0.05
0.1
0.15
0.2
0.25
0.3
Oo
cyst
s/10
L
Clostridium/100ml
No. of oocysts /10L
18
0.00.10.20.30.40.50.60.70.80.91.01.1
Tur
bidi
ty (N
TU
)
In line turbidity of filter outletGrab sample of final water turbidity
Standard 1 NTU
Turbidity
Source: Carlow County Council
19
0
5
10
15
20
25
30
3531
-Dec
3-Ja
n
10-J
an
17-J
an
24-J
an
31-J
an
7-F
eb
14-F
eb
21-F
eb
28-F
eb
7-M
ar
14-M
ar
21-M
ar
28-M
ar
4-A
pr
11-A
pr
18-A
pr
25-A
pr
02-M
ay
Week commencing
Nu
mb
er o
f ca
ses
by
onse
t
0
5
10
15
20
25
30
35
Rai
nfa
ll (m
m)
Date of Onset
Rainfall
Rainfall levels & onset of illness
20
Advice to vulnerable populations
• Infants– Widespread availability/use of bottled water
– FSAI recommendations
• Immunocompromised– Advised through medical professionals
– Recommendations• UK and USA
• Proposed Irish guidelines
• Recommendations of IRT
21
Communication
• Proactive– Council meetings
– Press interviews
– Notice distribution and updates
– Helpline
– Website
– FAQs
– Links
• Website www.carlow.ie
22
Communication - interagency
• Health Service and County Council– IRT – engineers, EHOs, public health doctors,
surveillance scientists, microbiologist– Protocol for microbiological incidents– Water Liaison group meetings
• Reports written in collaboration• Presentations supported • Regular meetings• Update protocol
23
Lessons learned
• Interpretation of water results
• Advice to vulnerable groups
• Importance of communication
• Building good working relationships
• Management of water incidents is complex and requires input from several different disciplines.
24
Acknowledgements
• HSE-SE staff & Carlow County Council
• Dr Phil Jennings, A/DPH, HSE-M
• Dr Derval Igoe/Dr Paul McKeown, HPSC
• Dr Maire O’Connor, Consultant in PHM, HSE-E
• Dr Gordon Nichols, Deputy Head, Environmental & Enteric Diseases Dept, HPA
• Dr David Stewart, DPH, EHSSB
• Ms Gemma Leane, HSE-SE
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