1. - - Queen’s CHRP Study - Enhanced Disease Surveillance of GI Outbreaks Caused By Drinking Water Contamination Dr. Yves Filion Dr. Kieran Moore Dr. Anna Majury Dr. Kevin Hall

2. Outline State of Canadian water infrastructure Mechanisms of system contamination Queen’s CFI study: enhanced GI detection Queen’s CHRP study: decision support for GI outbreak response

3. Water Infrastructure: Canadian Context Water systems in Ontario date from 50s and 60s Infrastructure debt in Canada is $60B (PEO ‘08) As of March 31/08, 1766 boil-waters (CMAJ) Canadian water systems are vulnerable…

4. Mechanisms of System Contamination Treatment failure (North Battleford, Milwaukee) Network intrusion caused by hydraulic transients Accidental Deliberate Injection of biological agents:  Hydrants  Pump stations  Water treatment facilities Contaminated GW Soil Pipe

5. Transport of Biological Agents in Water Distribution Systems Tank PS Network as delivery system Agent carried by pipe advection Human exposure through water consumption Large human populations susceptible to exposure Risk of Exposure Intrusion Point

6. Queen’s CFI Study - Enhanced Detection of Gastrointestinal Illness GIS-based GI detection algorithm Multivariate detection with water quality and health data Water quality: turbidity, chlorine residual Health: customer complaints and OTC medication sales Pumping Station Tank Pharmacy #2 Pharmacy #1 WQ #1 Pharmacy #3 WQ #2 WQ #3 WQ #4 WQ #5

7. Queen’s CFI Study - Enhanced Detection of Gastrointestinal Illness Disease transmission model (DTM) to simulate outbreak data:  Turbidity, chlorine residual  Complaints, OTC sales DTM modules:  Hydraulic (pressure / flow)  Transport (pipe advection)  Dynamic disease evolution  Health-seeking behaviour (self-medication) Courtesy of US EPA, http://www.epa.gov/nrmrl/wswrd/dw/epanet.html.

8. Queen’s CHRP Study - Decision Support for GI Outbreak Response Objective: combine detection with decision support capabilities to enhance inter- agency outbreak communication and coordination between water utilities and health units Project: DSS that integrates water quality data and nontraditional health data with expert knowledge

9. Queen’s CHRP Study - DSS DSS Chlorine Turbidity Water Complaints Expert Knowledge Engineer Clinical Epidemiologist Clinical Microbiologist Physician Telehealth OTC Medication ED Chief Complaint (GI)

10. Thoughts and Discussion...