WATERBORNE INFECTIOUS DISEASES

David L. Taylor, PhDInfection Preventionist

Dept of Clinical EpidemiologyThe Ohio State University Medical Center

Discussion:

• Sources and microbial etiologies of waterborne infections• Interesting outbreak associated with contaminated water

WHO GETS INFECTED?

• All of us• Normal, healthy people• Adults• Kids – worldwide (2 million deaths)• Sick people

HOW DO WE GET INFECTED?

• Water• Fecal contamination• Secondary cases• Hands• Environment• Food

FROM WHERE?

• Normal water microbes• Fecal contamination of water• Animals• Wild animals• Farm animals• People

• Feces• Vomitus• Hands

WHAT ARE THE WATER SOURCES?

• Surface water• Well water• Recreational water

- lakes, pools, hot tubs, etc• Cruises• Healthcare facilities

- Droplets, Rinse water, Hydrotherapy, Birthing, Warming baths, Holy water

WHAT MICROBES?(# OF CASES, OHIO, 2002)

• Bacteria ParasitesSalmonella (1400) Giardia (1000)Escherichia coli (200)

Cryptosporidium(120)Shigella (600) Viruses

Campylobacter(1300) NorovirusLegionella (26) Hepatitis A ((1400)Mycobacterium

COMMON INFECTIONS & CHARACTERISTICS

Incub SickSalmonella 12-48 hr 4-7 dE. coli 12-48 hr 2-7 dShigella 12-96 hr 2-7 dCampylobacter 2-5 d 7 dGiardia 1-2 wks 2-6 wksNorovirus 12-48 hr 12-24 hr

HOW ARE INFECTIONS TREATED?

• Salmonella – not generally treated – prolongs “carrier state”• E coli – generally not treated• Shigella – frequently treated – questioned: develop resistance?• Campylobacter – not treatedGiardia – treated• Norovirus – no antiviral therapy available

HOW ARE THE INFECTIONS PREVENTED?

• Don’t drink contaminated water• Treat water• Boil water• Point-of-use filter• Bleach• Hand hygiene • Prevent contamination of water

OUTBREAKSDrinking Water, ’91-’92

• 17 states - 34 outbreaks - 17,464 people• 11 outbreaks with identified agent

7 of 11, Giardia or CryptosporidiumSurface-influenced groundwater

Shigella & Hep A – contaminated well water• 68% no etiology; 1 outbreak of 9,847 people• 76% involved well water

OUTBREAKSRecreational Water, ’91-’92

• 21 states - 39 outbreaks - 1,825 people• 12 outbreaks - Pseudomonas dermatitis - hot tubs• 11 outbreaks – swimming

6 Giardia or Cryptosporidium1 E coli enterotoxigenicAmoebic meningoencephalitis - 6 deaths

OHIO OUTBREAKS

• 2002 – 3 outbreaksFebruary 1March 1June 1

• 2001 – 1 outbreak• 2000 – 1 outbreak

SOUTH BASS ISLAND OUTBREAK – an interesting

outbreak here in Ohio

• History of travel to So Bass Island• History of gastroenteritis• ODH notified August 3, 2004• May 30 – Sept 10 (3 ½ months)• Sporadic cases June, peaked in July & Aug, decreased after August 19• Over 1450 people

SOUTH BASS ISLAND OUTBREAK (2)

• Case-control study• Questionnaires:

Initially generalThen more specific - water

• Sources of water:Municipal water & well waterTreated water from Lake Erie to Put-in-

BayWells on western side of islandWells supplement municipal water

SOUTH BASS ISLAND OUTBREAK (3)

• Cases “more likely to drink tap water than were controls.”• Difficult to tell where water came from

Wells supplement municipal water at various times

Drank from different sites (business, home, motel, etc)

Where did they drink when they acquired the microbe?

SOUTH BASS ISLAND OUTBREAK (4)

• Confirmed positive specimens (of 155):15 Campylobacter9 Norovirus1 Salmonella1 Giardia

• Difficult to get specimensCalifornia, CanadaShort illness, better before getting

specimen

SOUTH BASS ISLAND OUTBREAK (5)

• Cases peaked at beginning of week (Mon, Tues)• Only 155 specimens• Investigated by CDC, state and local (Ottawa County) health departments, EPA• 42 wells tested - 32 positive for “coliforms”

SOUTH BASS ISLAND OUTBREAK (6)

• EPA Orders (issued 9/3/04)- “No Use Orders” – for drinking, preparing food, washing dishes, hand washing,

showering, or oral care- Facilities with no results returned –

inspect water treatment equipment & test more frequently

- To Put-in-Bay – ensure compliance with drinking water regulations and inspect

every service for presence of auxiliary wells

SOUTH BASS ISLAND OUTBREAK (8)

• Safe Drinking Water Guidelines- With wells – consider drinking bottled

water or water that has been at a rolling boil for at least one minute

- Use disinfected, bottled or boiled water for drinking, cooking, making prepared drinks, or brushing your teeth

- Practice thorough & frequent hand washing

WATERBORNE INFECTIONS SUMMARY

• Who• How• Sources• Microbes• Outbreaks• South Bass Island Outbreak

INFECTION PREVENTION

IS IN YOUR HANDS