1. WATERBORNE INFECTIOUS DISEASES David L. Taylor, PhD Infection Preventionist Dept of Clinical Epidemiology The Ohio State University Medical Center

2. Discussion: Sources and microbial etiologies of waterborne infections Interesting outbreak associated with contaminated water

3. WHO GETS INFECTED? All of us Normal, healthy people Adults Kids – worldwide (2 million deaths) Sick people

4. HOW DO WE GET INFECTED? Water Fecal contamination Secondary cases Hands Environment Food

5. FROM WHERE? Normal water microbes Fecal contamination of water Animals Wild animals Farm animals People Feces Vomitus Hands

6. 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

7. WHAT MICROBES? (# OF CASES, OHIO, 2002) Bacteria Parasites Salmonella (1400)Giardia (1000) Escherichia coli (200)Cryptosporidium(120) Shigella (600)Viruses Campylobacter(1300)Norovirus Legionella (26)Hepatitis A ((1400) Mycobacterium

8. COMMON INFECTIONS & CHARACTERISTICS IncubSick Salmonella12-48 hr4-7 d E. coli12-48 hr2-7 d Shigella12-96 hr2-7 d Campylobacter2-5 d7 d Giardia1-2 wks2-6 wks Norovirus12-48 hr12-24 hr

9. 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

10. 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

11. OUTBREAKS Drinking Water, ’91-’92 17 states - 34 outbreaks - 17,464 people 11 outbreaks with identified agent 7 of 11, Giardia or Cryptosporidium Surface-influenced groundwater Shigella & Hep A – contaminated well water 68% no etiology; 1 outbreak of 9,847 people 76% involved well water

12. OUTBREAKS Recreational Water, ’91-’92 21 states - 39 outbreaks - 1,825 people 12 outbreaks - Pseudomonas dermatitis - hot tubs 11 outbreaks – swimming 6 Giardia or Cryptosporidium 1 E coli enterotoxigenic Amoebic meningoencephalitis - 6 deaths

13. OHIO OUTBREAKS 2002 – 3 outbreaks February1 March1 June1 2001 – 1 outbreak 2000 – 1 outbreak

14. 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

15. SOUTH BASS ISLAND OUTBREAK (2) Case-control study Questionnaires: Initially general Then more specific - water Sources of water: Municipal water & well water Treated water from Lake Erie to Put-in-Bay Wells on western side of island Wells supplement municipal water

16. 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?

17. SOUTH BASS ISLAND OUTBREAK (4) Confirmed positive specimens (of 155): 15 Campylobacter 9 Norovirus 1 Salmonella 1 Giardia Difficult to get specimens California, Canada Short illness, better before getting specimen

18. 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”

19. 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

20. 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

21. WATERBORNE INFECTIONS SUMMARY Who How Sources Microbes Outbreaks South Bass Island Outbreak

22. INFECTION PREVENTION IS IN YOUR HANDS