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Note:Cryptosporidium oocysts are not effectively inactivated by alcohol-based hand sanitizers.
At child care facilities
Exclude children with diarrhea from child care settings until the diarrhea has stopped.
At the pool
Protect others by not swimming if you are experiencing diarrhea (this is essential for children in diapers). If cryptosporidiosis is diagnosed, do not swim for at least 2 weeks after diarrhea stops.
Shower before entering the water.
Wash children thoroughly (especially their bottoms) with soap and water after they use the toilet or their diapers are changed and before they enter the water.
Take children on frequent bathroom breaks and check their diapers often.
Change diapers in the bathroom, not at the poolside.
Minimize contact with the stool of all animals, particularly young animals.
Wear disposable gloves when cleaning up after a pet, and always wash hands when finished.
Wash hands after any contact with animals or their living areas.
Outside
Wash hands after gardening, even if wearing gloves.
Immunocompromised persons
Avoid close contact with anyone who has cryptosporidiosis. Cryptosporidiosis can become a life-threatening disease for immunocompromised persons.
Do not handle animal feces because infection can be life-threatening for immunocompromised persons.
Avoid water (drinking and recreational) that might be contaminated.
Do not swallow water while swimming in swimming pools, spas, interactive fountains, lakes, rivers, springs, ponds, streams or the ocean.
Reduce contamination of treated recreational water venues by having pool operators install in-line secondary or supplemental disinfection systems (e.g., ultraviolet light and ozone) to inactivate this chlorine-tolerant parasite.
Do not drink untreated water from lakes, rivers, springs, ponds, streams, or shallow wells.
Do not drink inadequately treated water or ice made from water during communitywide outbreaks caused by contaminated drinking water.
Do not use or drink inadequately treated water or use ice when traveling in countries where the water supply might be unsafe.
If the safety of drinking water is in doubt (e.g., outbreak, poor sanitation, and lack of water treatment systems),
drink bottled water, or
disinfect by heating the water to a rolling boil for 1 minute, or
use a filter that has been tested and rated by National Sanitation Foundation (NSF) Standard 53 or NSF Standard 58 for cyst and oocyst reduction; filtered water will need additional treatment to kill or inactivate bacteria and viruses.
Avoid Recreational Water Illnesses! Don’t swim when ill with diarrhea; don’t get water in your mouth; practice good hygiene.
Recreational water illnesses (RWIs) are caused by germs spread by swallowing, breathing in mists or aerosols from, or having contact with contaminated recreational water. Recreational water includes water in swimming pools, hot tubs, water parks, water play areas, interactive fountains, lakes, rivers, or oceans. The most commonly reported RWI is diarrhea. Diarrheal illnesses can be caused by germs such as Crypto (short for Cryptosporidium), Giardia, Shigella, norovirus, and E. coli O157:H7. They can be spread by swallowing water that has been contaminated with fecal matter containing these germs.
Over the last 31 years (1978-2008), the number of reported RWI outbreaks has steadily increased, from as few as 5 in 1986 to as many as 84 in 2007. The most notable increases in the number of RWI outbreaks occurred after 1997.
These overall increases are the result of a surge in the number of reported outbreaks of acute diarrheal illness (gastroenteritis) linked to recreational water venues treated with chlorine, such as swimming pools. Several factors may have contributed to the increase. First, there might have been a true increase in the number of annual RWI outbreaks. Second, heightened awareness of RWIs among swimmers, healthcare providers, and health departments may have led to an improvement in the detection and reporting of outbreaks.
What is certain is that the increases in the number of reported RWI outbreaks of acute diarrheal illness (gastroenteritis) are the result of increased reporting of outbreaks caused by Crypto. The chlorine in pools and other treated recreational water venues kills germs, usually within a few minutes. One important exception to this rule is Crypto. Crypto has a hard outer shell that makes the germ especially difficult to kill and allows it to live for days, even in properly chlorinated pools.
You share the water—and the germs in it—with every person who enters the pool. This means that just one person with diarrhea can easily contaminate the water. Swallowing even a small amount of pool water that has been contaminated with the germs that cause diarrhea can make you sick. Take action to reduce the spread of RWIs! Follow the steps below to help ensure that your swimming experience is healthy and RWI-free.
Protect yourself and others from RWIs and follow the Six Steps for Healthy Swimming:
Three Steps for All Swimmers
Don’t swim when you have diarrhea. You can spread germs in the water and make other people sick.
Don’t swallow the pool water. Avoid getting water in your mouth.
Practice good hygiene. Shower with soap before swimming and wash your hands after using the toilet or changing diapers. Germs on your body end up in the water.
Three Steps for Parents of Young Kids
Take your kids on bathroom breaks or check diapers often. Waiting to hear “I have to go” may mean that it’s too late.
Change diapers in a bathroom or a diaper-changing area and not at poolside. Germs can spread in and around the pool.
Wash your child thoroughly (especially the rear end) with soap and water before swimming. Invisible amounts of fecal matter can end up in the pool.
Data Source:
Yoder J, Hlavsa M, Craun GF, Hill V, Roberts V, Yu P, Hicks LA, Alexander NT, Calderon RL, Roy SL, Beach MJ. (2008) Surveillance for waterborne disease and outbreaks associated with recreational water use and other aquatic facility-associated health events — United States, 2005–2006. MMWR Surveill Summ 57:1-38.
Notes from the Field: Salmonella Typhi Infections Associated with Contaminated Water — Zimbabwe, October 2011–May 2012
Weekly
June 15, 2012 / 61(23);435-435
On October 25, 2011, a cluster of approximately 20 suspected cases of typhoid fever in residents of Dzivaresekwa, a high-density suburb of Harare, Zimbabwe, was reported to the City of Harare City Health Department. On November 22, a team from CDC-Atlanta, CDC-Kenya/Kenya Medical Research Institute, and the South Africa Field Epidemiology and Laboratory Training Program, was invited to assist with the investigation by providing epidemiologic and microbiologic support to better describe the outbreak and to evaluate response efforts.
As of May 2, 2012, a total of 4,185 suspected cases of typhoid fever had been identified in Harare. Suspected cases were defined as fever of ≥3 days duration and malaise, headache, vomiting, diarrhea, constipation, or cough in a person who lived in or had been in Harare since October 1, 2011. Confirmed cases (n = 52) met the suspected case definition and were confirmed by blood or stool culture. Median age of patients was 15 years (range: <1–95 years); 54% were female. Hospitalization was reported for 1,788 patients (43%); two deaths were reported. Suspected cases were reported predominantly in the high-density suburbs of Kuwadzana (1,957), Dzivaresekwa (1,012), and Marlborough (115). Of patients treated in Harare, 207 reported home addresses in other Zimbabwean provinces. Suspected cases of typhoid fever in Harare continue to decline as of May 2, 2012; however, with limited surveillance systems and laboratory capacity, national trends are unclear.
The investigative team, in collaboration with government officials, tested water samples from six public boreholes, seven shallow wells, and three municipal taps in Dzivaresekwa. Samples from two of six boreholes and all seven shallow wells yielded Escherichia coli (an indicator of fecal contamination); all municipal taps tested negative for E. coli.
Recommendations included promotion of household chlorination of water from all sources because chlorination of the municipal system might be unreliable. Public health partners targeted distribution of a 3-month supply of sodium dichloroisocyanurate water-purification tablets (i.e., enough tablets to treat a single 20-liter bucket for drinking water every day per household for 3 months) to all households in suburbs that were defined as being at high risk, and disseminated health education messages highlighting the importance of safe water collection, treatment, and storage, safe food preparation, and improved hygiene and sanitation practices. Efforts are under way to upgrade infrastructure (replacing old cast-iron pipes with new polyvinyl chloride pipes to prevent breakages), remediate existing boreholes by shock chlorination and drilling new ones, and establish local reservoir tanks.
Although this descriptive study does not prove that illness was associated with contaminated water, the association seems likely. Rural-to-urban migration has resulted in overcrowding in residential areas and has outpaced maintenance and expansion of water supply and sewerage infrastructure. Rationing of piped, treated water from municipal systems obliges residents to use unimproved water sources to meet their water needs, putting them at risk for enteric infections. Frequent sewer blockages compound this problem by further contaminating shallow wells used by residents for drinking water.
Each year, Salmonella Typhi causes an estimated 22 million cases of typhoid fever and 216,000 deaths worldwide (1). Humans are the only reservoir for S. Typhi, and infection occurs by the fecal-oral route, usually through ingestion of contaminated food or water. An estimated 884 million persons worldwide lack access to safe water, and nearly 2.5 billion persons do not have access to adequate sanitation (2). Incidence is highest in developing countries, particularly in areas with poor sanitation or without access to safe water. Recent evidence of the magnitude of epidemic and endemic typhoid fever in sub-Saharan African countries highlights the continued importance of typhoid fever prevention and control in Africa (3).
References
Crump JA, Luby SP, Mintz ED. The global burden of typhoid fever. Bull World Health Organ 2004;82:346–53.
Borchardt MA, Spencer SK, Kieke BA, et al. Viruses in non-disinfected drinking water from municipal wells and community incidence of acute gastrointestinal illness. Environ Health Perspect 2012 Jun 1
Background: Groundwater supplies for drinking water are frequently contaminated with low-levels of human enteric virus genomes, yet evidence for waterborne disease transmission is lacking.
Conclusions: The majority of groundwater-source public water systems in the USA produce water without disinfection. Our findings suggest that populations served by such systems may be exposed to waterborne viruses and consequent health risks.
Borchardt MA, Spencer SK, Kieke BJA, Lambertini E, Loge FJ 2012. Viruses in Non-Disinfected Drinking Water from Municipal Wells and Community Incidence of Acute Gastrointestinal Illness. Environ Health Perspect :-. http://dx.doi.org/10.1289/ehp.1104499
St. Paul, Minn. — “Ninety-seven people have reported cases of cryptosporidiosis since last month’s outbreak at Edgewater Resort and Water Park in Duluth, according to the Minnesota Department of Health. Twenty-two of those cases have been confirmed in laboratories.
Minnesota Department of Health (MDH) epidemiologist Trisha Robinson said the confirmed cases probably only represent a fraction of people who were actually sickened by the parasite. The investigation of the outbreak is still in progress….”
Announcements: Ground Water Awareness Week — March 11–17, 2012
Weekly
March 9, 2012 / 61(09);163
CDC is collaborating with the National Ground Water Association to highlight National Ground Water Awareness Week, March 11–17, 2012. Water is essential for life. However, many persons are not aware that much of the water they use flows from below ground to the surface, where it is used by public water systems and private wells. The National Ground Water Association uses this week to stress ground water’s importance to the health and well-being of humans and the environment (1).
The majority of public water systems in the United States use ground water as their primary source, providing drinking water to almost 90 million persons (2). An additional 15 million U.S. homes use private wells, which also rely on ground water (3).
Usually, ground water in the United States is safe to use. However, ground water sources can be contaminated naturally or as a result of imperfect agricultural, manufacturing, or sanitary practices. The presence of contaminants such as pesticides, factory waste, and sewage can lead to acute and chronic illness (4).
The U.S. Environmental Protection Agency has worked with individual states to develop new regulations to provide increased protection against microbial pathogens in public water systems that use ground water sources (5). Private ground water wells (serving fewer than 25 persons) might not be regulated but nonetheless must be properly maintained by well owners to ensure that the water remains free from harmful chemicals and pathogens.* Resources are available from state and local health departments to help homeowners protect their ground water.†
US Environmental Protection Agency. Factoids: drinking water and ground water statistics for 2009. Washington, DC: US Environmental Protection Agency, Office of Water; 2009. Available at http://www.epa.gov/ogwdw/databases/pdfs/data_factoids_2009.pdf . Accessed March 7, 2012.
US Census Bureau. Current housing reports: American housing survey for the United States: 2009. Washington, DC: US Government Printing Office; 2011. Available at http://www.census.gov/prod/2011pubs/h150-09.pdf . Accessed March 7, 2012.
US Environmental Protection Agency. Drinking water contaminants. Washington, DC: US Environmental Protection Agency; 2012. Available at http://www.epa.gov/safewater/contaminants/index.html. Accessed March 7, 2012.
UNICEF fights “one of the worst ever” cholera outbreaks in West and Central Africa
DAKAR/GENEVA, 11 October 2011 – UNICEF is calling for a redoubling of efforts to combat cholera outbreaks that are claiming lives and affecting large numbers of people across West and Central Africa.
This year has seen more than 85,000 reported cases of cholera, resulting in 2,466 deaths. The size and scale of the outbreaks mean the region is facing one of the biggest epidemics in its history. In addition Case Fatality Rates (CFR) are unacceptably high, ranging from 2.3 per cent to 4.7 per cent and can reach much higher levels at district level in many countries (ranging from 1 per cent to 22 per cent in Cameroon for example). Children are more vulnerable to cholera, as they dehydrate faster, and malnourished children are especially at risk.
The most significant increases in 2011 are in Chad, Cameroon and in western Democratic Republic of Congo (DRC). In addition there are still challenges with getting access, ensuring staff presence in medical facilities and establishing surveillance systems to monitor cases and numbers in parts of North-East DRC.
There are three major cross border cholera epidemic outbreaks in West and Central Africa: the Lake Chad Basin (Chad, Cameroon, Nigeria and Niger), the West Congo Basin (DRC, Congo and the Central African Republic) and Lake Tanganyika (DRC and Burundi). Smaller cholera epidemics in Benin, Cote d’Ivoire, Ghana, Guinea, Liberia, and Togo are under control.
UNICEF is providing treatment kits, conducting community awareness campaigns on hygiene and assisting with epidemiological surveys to ensure better targeting of control efforts. It is clear in this emergency that authorities can play a key role to save lives. Information exchange between cross- border districts on caseloads and population movements, as well as cross-border inspections for disinfection and chlorination are proven ways to contain the disease and save lives.
UNICEF calls upon governments to coordinate the preparation and response not only within their borders, but to ensure close collaboration with neighbouring countries. Cross-border coordination has to be encouraged at all levels, from the district to the national level.
A cross-border epidemiological study covering the Lake Chad Basin (Cameroon, Chad, Nigeria and Niger) was initiated by UNICEF in 2010, and is now in its second phase. The study provides critical evidence for informing cholera prevention and response interventions, which have to be coordinated across borders. Cross-border coordination between teams in Kinshasa and Brazzaville has also been initiated for the more recent cholera outbreak in the West Congo Basin.
Cholera is known as a disease that affects the poor because of the lack of access to clean water and improved sanitation. The best preventive measure against cholera is access to improved water supply, basic sanitation and hygiene.
Note to Editors Access rates to water and sanitation in West and Central Africa are among the lowest in the world. Out of 24 countries in the region, not a single one is on track to meet the MDG target for sanitation. This is the underlying cause for cholera outbreaks in West and Central Africa. Although measures for cholera response can help contain the spread of the disease and reduce the number of fatalities, it would be much more effective if the underlying cause of this ‘poor man’s disease’ is tackled.
About UNICEF UNICEF is on the ground in over 150 countries and territories to help children survive and thrive, from early childhood through adolescence. The world’s largest provider of vaccines for developing countries, UNICEF supports child health and nutrition, good water and sanitation, quality basic education for all boys and girls, and the protection of children from violence, exploitation, and AIDS. UNICEF is funded entirely by the voluntary contributions of individuals, businesses, foundations and governments. For more information about UNICEF and its work visit: http://www.unicef.org/
For more information, please contact: UNICEF in West and Central Africa: Martin Dawes,
Tel + 221 775 69 19 26 begin_of_the_skype_highlighting+ 221 775 69 19 26end_of_the_skype_highlighting mdawes@unicef.org
Surveillance for Waterborne Disease Outbreaks and Other Health Events Associated with Recreational Water — United States, 2007–2008
Surveillance Summaries
September 23, 2011 / 60(ss12);1-32
ABSTRACT
Problem/Condition: Since 1978, CDC, the U.S. Environmental Protection Agency, and the Council of State and Territorial Epidemiologists have collaborated on the Waterborne Disease and Outbreak Surveillance System (WBDOSS) for collecting and reporting data on waterborne disease outbreaks associated with recreational water. This surveillance system is the primary source of data concerning the scope and health effects of waterborne disease outbreaks in the United States. In addition, data are collected on other select recreational water–associated health events, including pool chemical–associated health events and single cases of Vibrio wound infection and primary amebic meningoencephalitis (PAM).
Reporting Period: Data presented summarize recreational water–associated outbreaks and other health events that occurred during January 2007–December 2008. Previously unreported data on outbreaks that have occurred since 1978 also are presented.
Description of the System: The WBDOSS database includes data on outbreaks associated with recreational water, drinking water, water not intended for drinking (excluding recreational water), and water use of unknown intent. Public health agencies in the states, the District of Columbia, U.S. territories, and Freely Associated States are primarily responsible for detecting and investigating waterborne disease outbreaks and voluntarily reporting them to CDC using a standard form. Only data on outbreaks associated with recreational water are summarized in this report. Data on other recreational water–associated health events reported to CDC, the Agency for Toxic Substances and Disease Registry (ATSDR), and the U.S. Consumer Product Safety Commission (CPSC) also are summarized.
Results: A total of 134 recreational water–associated outbreaks were reported by 38 states and Puerto Rico for 2007–2008. These outbreaks resulted in at least 13,966 cases. The median outbreak size was 11 cases (range: 2–5,697 cases). A total of 116 (86.6%) outbreaks were associated with treated recreational water (e.g., pools and interactive fountains) and resulted in 13,480 (96.5%) cases. Of the 134 outbreaks, 81 (60.4%) were outbreaks of acute gastrointestinal illness (AGI); 24 (17.9%) were outbreaks of dermatologic illnesses, conditions, or symptoms; and 17 (12.7%) were outbreaks of acute respiratory illness. Outbreaks of AGI resulted in 12,477 (89.3%) cases.
The etiology was laboratory-confirmed for 105 (78.4%) of the 134 outbreaks. Of the 105 outbreaks with a laboratory-confirmed etiology, 68 (64.8%) were caused by parasites, 22 (21.0%) by bacteria, five (4.8%) by viruses, nine (8.6%) by chemicals or toxins, and one (1.0%) by multiple etiology types. Cryptosporidium was confirmed as the etiologic agent of 60 (44.8%) of 134 outbreaks, resulting in 12,154 (87.0%) cases; 58 (96.7%) of these outbreaks, resulting in a total of 12,137 (99.9%) cases, were associated with treated recreational water. A total of 32 pool chemical–associated health events that occurred in a public or residential setting were reported to WBDOSS by Maryland and Michigan. These events resulted in 48 cases of illness or injury; 26 (81.3%) events could be attributed at least partially to chemical handling errors (e.g., mixing incompatible chemicals). ATSDR’s Hazardous Substance Emergency Events Surveillance System received 92 reports of hazardous substance events that occurred at aquatic facilities. More than half of these events (55 [59.8%]) involved injured persons; the most frequently reported primary contributing factor was human error. Estimates based on CPSC’s National Electronic Injury Surveillance System (NEISS) data indicate that 4,574 (95% confidence interval [CI]: 2,703–6,446) emergency department (ED) visits attributable to pool chemical–associated injuries occurred in 2008; the most frequent diagnosis was poisoning (1,784 ED visits [95% CI: 585--2,984]). NEISS data indicate that pool chemical–associated health events occur frequently in residential settings. A total of 236 Vibrio wound infections were reported to be associated with recreational water exposure; 36 (48.6%) of the 74 hospitalized vibriosis patients and six (66.7%) of the nine vibriosis patients who died had V. vulnificus infections. Eight fatal cases of PAM occurred after exposure to warm untreated freshwater.
Interpretations: The 134 recreational water–associated outbreaks reported for 2007–2008 represent a substantial increase over the 78 outbreaks reported for 2005–2006 and the largest number of outbreaks ever reported to WBDOSS for a 2-year period. Outbreaks, especially the largest ones, were most frequently associated with treated recreational water and characterized by AGI. Cryptosporidium remains the leading etiologic agent. Pool chemical–associated health events occur frequently but are preventable. Data on other select recreational water–associated health events further elucidate the epidemiology of U.S. waterborne disease by highlighting less frequently implicated types of recreational water (e.g., oceans) and detected types of recreational water–associated illness (i.e., not AGI).
Public Health Actions: CDC uses waterborne disease outbreak surveillance data to 1) identify the types of etiologic agents, recreational water venues, and settings associated with waterborne disease outbreaks; 2) evaluate the adequacy of regulations and public awareness activities to promote healthy and safe swimming; and 3) establish public health priorities to improve prevention efforts, guidelines, and regulations at the local, state, and federal levels.
Problem/Condition: Since 1971, CDC, the Environmental Protection Agency (EPA), and the Council of State and Territorial Epidemiologists have collaborated on the Waterborne Disease and Outbreak Surveillance System (WBDOSS) for collecting and reporting data related to occurrences and causes of waterborne disease outbreaks associated with drinking water. This surveillance system is the primary source of data concerning the scope and health effects of waterborne disease outbreaks in the United States.
Reporting Period: Data presented summarize 48 outbreaks that occurred during January 2007–December 2008 and 70 previously unreported outbreaks.
Description of System: WBDOSS includes data on outbreaks associated with drinking water, recreational water, water not intended for drinking (WNID) (excluding recreational water), and water use of unknown intent (WUI). Public health agencies in the states, U.S. territories, localities, and Freely Associated States are primarily responsible for detecting and investigating outbreaks and reporting them voluntarily to CDC by a standard form. Only data on outbreaks associated with drinking water, WNID (excluding recreational water), and WUI are summarized in this report. Outbreaks associated with recreational water are reported separately.
Results: A total of 24 states and Puerto Rico reported 48 outbreaks that occurred during 2007–2008. Of these 48 outbreaks, 36 were associated with drinking water, eight with WNID, and four with WUI. The 36 drinking water–associated outbreaks caused illness among at least 4,128 persons and were linked to three deaths. Etiologic agents were identified in 32 (88.9%) of the 36 drinking water–associated outbreaks; 21 (58.3%) outbreaks were associated with bacteria, five (13.9%) with viruses, three (8.3%) with parasites, one (2.8%) with a chemical, one (2.8%) with both bacteria and viruses, and one (2.8%) with both bacteria and parasites. Four outbreaks (11.1%) had unidentified etiologies. Of the 36 drinking water–associated outbreaks, 22 (61.1%) were outbreaks of acute gastrointestinal illness (AGI), 12 (33.3%) were outbreaks of acute respiratory illness (ARI), one (2.8%) was an outbreak associated with skin irritation, and one (2.8%) was an outbreak of hepatitis. All outbreaks of ARI were caused by Legionella spp.
A total of 37 deficiencies were identified in the 36 outbreaks associated with drinking water. Of the 37 deficiencies, 22 (59.5%) involved contamination at or in the source water, treatment facility, or distribution system; 13 (35.1%) occurred at points not under the jurisdiction of a water utility; and two (5.4%) had unknown/insufficient deficiency information. Among the 21 outbreaks associated with source water, treatment, or distribution system deficiencies, 13 (61.9%) were associated with untreated ground water, six (28.6%) with treatment deficiencies, one (4.8%) with a distribution system deficiency, and one (4.8%) with both a treatment and a distribution system deficiency. No outbreaks were associated with untreated surface water. Of the 21 outbreaks, 16 (76.2%) occurred in public water systems (drinking water systems under the jurisdiction of EPA regulations and water utility management), and five (23.8%) outbreaks occurred in individual systems (all of which were associated with untreated ground water). Among the 13 outbreaks with deficiencies not under the jurisdiction of a water system, 12 (92.3%) were associated with the growth of Legionella spp. in the drinking water system, and one (7.7%) was associated with a plumbing deficiency. In the two outbreaks with unknown deficiencies, one was associated with a public water supply, and the other was associated with commercially bottled water. The 70 previously unreported outbreaks included 69 Legionella outbreaks during 1973–2000 that were not reportable previously to WBDOSS and one previously unreported outbreak from 2002.
Interpretation: More than half of the drinking water–associated outbreaks reported during the 2007–2008 surveillance period were associated with untreated or inadequately treated ground water, indicating that contamination of ground water remains a public health problem. The majority of these outbreaks occurred in public water systems that are subject to EPA’s new Ground Water Rule (GWR), which requires the majority of community water systems to complete initial sanitary surveys by 2012. The GWR focuses on identification of deficiencies, protection of wells and springs from contamination, and providing disinfection when necessary to protect against bacterial and viral agents. In addition, several drinking water–associated outbreaks that were related to contaminated ground water appeared to occur in systems that were potentially under the influence of surface water. Future efforts to collect data systematically on contributing factors associated with drinking water outbreaks and deficiencies, including identification of ground water under the direct influence of surface water and the criteria used for their classification, would be useful to better assess risks associated with ground water.
During 2007–2008, Legionella was the most frequently reported etiology among drinking water–associated outbreaks, following the pattern observed since it was first included in WBDOSS in 2001. However, six (50%) of the 12 drinking water–associated Legionella outbreaks were reported from one state, highlighting the substantial variance in outbreak detection and reporting across states and territories. The addition of published and CDC-investigated legionellosis outbreaks to the WBDOSS database clarifies that Legionella is not a new public health issue. During 2009, Legionella was added to EPA’s Contaminant Candidate List for the first time.
Public Health Actions: CDC and EPA use WBDOSS surveillance data to identify the types of etiologic agents, deficiencies, water systems, and sources associated with waterborne disease outbreaks and to evaluate the adequacy of current technologies and practices for providing safe drinking water. Surveillance data also are used to establish research priorities, which can lead to improved water quality regulation development. Approximately two thirds of the outbreaks associated with untreated ground water reported during the 2007–2008 surveillance period occurred in public water systems. When fully implemented, the GWR that was promulgated in 2006 is expected to result in decreases in ground water outbreaks, similar to the decreases observed in surface water outbreaks after enactment of the Surface Water Treatment Rule in 1974 and its subsequent amendments. One third of drinking water–associated outbreaks occurred in building premise plumbing systems outside the jurisdiction of water utility management and EPA regulations; Legionella spp. accounted for >90% of these outbreaks, indicating that greater attention is needed to reduce the risk for legionellosis in building plumbing systems. Finally, a large communitywide drinking water outbreak occurred in 2008 in a public water system associated with a distribution system deficiency, underscoring the importance of maintaining and upgrading drinking water distribution system infrastructure to provide safe water and protect public health.
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