Avoiding the Risk of Water-borne Disease - PowerPoint Presentation

1. Avoiding the Risk of Water-borne Disease Autumn Grim, MPHEpidemiologist/Program CoordinatorMissouri Department of Health & Senior Services

2. “We never know the worth of water till the well is dry.” -Thomas Fuller

3. Water Essential to LifeWater is a fundamental human need.Each person on Earth requires at least 20 – 50 liters of clean, safe water a day for drinking, cooking, and simply keeping themselves clean.Polluted water is not only dirty but can be deadly.The United Nations considers universal access to clean water a basic human right.

4. Way of LifePeople depend on clean water for their health.Healthy ecosystems provide wildlife habitat and places to fish, paddle, surf and swim.Economy depends on clean water: manufacturing, farming, tourism, recreation, energy production, and other economic sectors need clean water to function and flourish. *EPA Clean Water Rule

5. Everything is ConnectedAnalyzing water’s economic importance reveals that everything is connected. Water may be a local resource but water use is connected at regional or watershed levels and through commerce, trade and other linkages it is connected even at the national or international level.Changes to water use or impacts in one sector can have significant effects across many regions and have long lasting ripple effects.

6. Water Utilities and Public HealthA systems approach is invaluable in considering this interconnected relationship.Not only necessary to communicate with each other but also essential to actively work together to effectively respond to potential contamination events.Accidental events.Intentional contamination events.

7. Indicators of ContaminationThe first indication of contamination will likely come through the public health system.Ill individuals will seek medical care at a health care center that reports illness to local health departments.Routine monitoring of community surveillance sites may suggest a concern.Nursing homes are very good indicators of water-borne illness.

8. Possible Contamination EventsMay be biological in nature.These will be naturally occurring micro-organisms or pathogens that find their way into a water system.May be chemical in nature.May occur in the disinfection process or some type of environmental spill.

9. Pathogens Transmitted via WaterThere are 13 different micro-organisms that can be transmitted via water.Most of the diseases can also be transmitted through other routes, such as contaminated food or having contact with a sick person.

10. Water-borne BurdenData collected by Centers for Disease Control (CDC) for 2017:6,939 annual total deaths were documented.Of the 6,939 deaths, 91% were associated with three environmental pathogens that can grow in water system biofilms:Legionella (Legionnaires' disease).Non-Tuberculosis Mycobacteria.Pseudomonas-related pneumonia or septicemia.

11. Water-borne Burden (cont’d)Of the 6,939 deaths, 7% were associated with seven pathogens transmitted by the fecal–oral route: CampylobacterCryptosporidiumE. coli GiardiaHepatitis ASalmonella non-typhoidalShigella 

12. Cost Estimates477,000 annual Emergency Department (ED) visits were documented for 2017.Annual treat-and-release ED visits resulted in $194 million in annual direct costs.Overall, the annual hospitalization and treat-and-release ED visit costs associated with the 13 diseases totaled to $3.8 billion.

13. Determining Cause of Water-borne Illness (Biological)Unique in infectious dose, symptoms, illness and growth conditions.Need water, food, warmth, time and pH.Temperature: Grow between 40-135ºF.Time: Lag Phase, Log Phase, Stationary Phase, Death Phase.

14. Water-borne IllnessCan occur through:Ingestion: Eating contaminated food or water; dirty hands, utensils, etc.Inhalation: Droplet or airborne spread from an infected individual.Through the skin: Insect or animal bites.

15. Famous Water-borne OutbreaksAll among public water systems:Walkerton, Canada – 2000: E. coli found in town’s well after chlorinator breaks down.Milwaukee – 1993: Cryptosporidium outbreak 403,000 people sick; 100 deaths, mostly people with AIDS, children with cancer.Cabool, Missouri – 1989 & 1990: First ever water-borne report of E. coli; 243 cases identified, 32 Hospitalized, 4 died.Gideon, MO – 1983: Salmonella Typhimurium; estimated 625 cases and 7 associated deaths.

16. Walkerton, Canada--2000E. coli found in town’s well water 5-7 times/year.Shallow wells, downhill from cattle farms.Identified by consulting engineer as problem. Cycle of excess chlorine followed by use of less disinfectant when taste bad.Rare inspections.April 2000 –chlorinator breaks down.

17. Walkerton TimelineApril 7 – 4 of 8 samples show contamination.April 24 – 2 people very ill from E. coli.May 12 – huge rainstorm, floods wells with manure run-off from farm.May 16 – water lab tests (+), few people now ill.May 17 – epidemic dysentery in Walkerton.May 19 – public health officials alerted, suspect epidemic. Chlorine levels in water half of what is required.May 20 – docs report more and more cases dysentery.May 21 – boil water order issued.May 22 – 100 confirmed cases.

18. Association Between Rainfall and Walkerton Outbreak

19. Milwaukee -- 1993Cryptosporidium outbreak.403,000 people sick.100 deaths, mostly people with AIDS, children with cancer.Resistant to chlorination.Present in 95% of surface waters.Water was taken from Lake Michigan.

20. MilwaukeeChlorination did not prevent this outbreak (plants treated water by adding chlorine and polyaluminum chloride).Marked increases in the turbidity of treated water at the city's southern water-treatment plant from March 23 until April 9.Cryptosporidium oocysts were identified in water from ice made in southern Milwaukee during these weeks.

21. Culprit at MilwaukeeCaused by cryptosporidium oocysts that passed through the filtration system of one of the city's water-treatment plants.The source of the oocysts remain speculative.Cattle along two rivers that flow into the Milwaukee harbor, slaughterhouses, and human sewage.Rivers that were swelled by spring rains and snow runoff may have transported oocysts.

22. Missouri Specific Water-borne Outbreaks-Cabool (1989-1990)243 cases identified (city population of 2,090).32 hospitalized.4 died.2 had Hemolytic Uremic Syndrome and required kidney dialysis.Unchlorinated water system.

23. Cabool, MO Of the 68 water samples collected between December 18 - January 12 from wells and distribution system:6 had total coliform counts of 1 per 100 mL and 1 had 2 per 100 mL.Federal drinking water regulations in place at that time deemed any sample with 1 or more coliforms per 100 mL as unsatisfactory.

24. Cabool, MODead end sites may have contributed to outbreak.5 dead end sites were sampled on February 15. 3 grew more than 50 coliforms per 100 mL when cultured by EPA.

25. Culprit at CaboolExtreme cold weather prior to outbreak caused 45 in- ground water meters to be replaced due to lines freezing or meter failure.2 large water main breaks as well.Agricultural run off from surrounding cattle.System wide chlorination or hyperchlorination during repairs might have prevented this outbreak.

26. Missouri Specific Water-borne Outbreaks-Gideon (1983)Salmonella Typhimurium (S. Typhimurium) outbreak.Unchlorinated system.Water system constructed in 1930s.Water provided by deep wells.3 water storage towers.

27. Gideon, MO (cont’d)Outbreak resulted in an estimated 625 cases and 7 deaths.Epidemiologic, environmental, and laboratory evidence indicate water system was source.Largest waterborne Salmonella outbreak since 1965.Resulted in more deaths than any other waterborne outbreak since 1941.

28. Gideon, MO (cont’d)31 culture-confirmed cases; 15 hospitalized.7 associated deaths; nursing home residents.Water from residential taps: 14/29 had coliforms detected, 9 had fecal coliforms, not cultured for Salmonella.Water from fire hydrants: 1/6 grew S. Typhimurium.Water from the water towers: not cultured but sediment from one of the towers grew S. Typhimurium.

29. Culprit at GideonDuring examination of water towers, it was discovered there was a hole large enough that birds could get in.Birds were noted to be roosting in the water tower.Birds commonly carry Salmonella.Adequate chlorination would have likely prevented this outbreak.

30. Another Infamous Water-borne Outbreak-Cape CountyCan occur in recreational venues as well.Recreational facility (70,000 square feet) using a private well (unchlorinated), that should have been registered as a public water system. Served over 500 patrons a week.Only commonality among individuals diagnosed with E. coli was drinking from the water fountain at this facility. 28 individuals with confirmed E. coli infection.

31. Water Analysis SummaryOf the 19 official water samples taken and analyzed at state approved certified laboratories, 14 (73.7%) were coliform positive. Of the 14 samples tested for E. coli, 6 (42.9%) of those were E. coli positive.

32. Culprit at Cape CountyThe facility is located southwest of a large cattle farm, in a valley that is beneath the cattle farm. Cattle are a known reservoir for E. coli.Heavy rains were reported by the National Weather Service (NWS) in the area prior to the outbreak. Approximately 2-3 days prior to illness onsets.

33. Rainfall amounts were significant prior to each peak on the epi curve (largest amounts for that month).Interesting Weather FeatureCape Girardeau E. coli Outbreak Epidemic Curve

34. Notice a Trend? All of these outbreaks occurred in water systems that were:Not chlorinated.Not well maintained.Older water systems.Followed extreme weather related events.

35. Increased Rainfall and Weather Related EventsSignificant link between excess rainfall and waterborne disease outbreaks, indicates that meteorological and climatological conditions need to be considered by water managers, public health officials, and private citizens as a significant risk factor for water contamination.A system to identify and project the impacts of such challenging or extreme weather conditions on water supply systems could be developed.

36. Increased Rainfall and Weather Related Events (cont’d)The use of weather monitoring and forecast information or a "wellhead alert system" could alert water system and water supply managers on the potential response of their systems to challenging weather conditions and additional requirements to protect health.Used by beach managers in parts of the United States to predict day-to-day water quality for beach advisories.

37. Disinfection with Chlorine/ChloramineChlorine was first used as a drinking water disinfectant in Europe in the late 1800s. It was first used in the U.S. in 1908 in Jersey City, New Jersey.Chloramine has been used as a drinking water disinfectant in the U.S. in places like Cleveland, Ohio, Springfield, Illinois, and Lansing, Michigan since 1929.*Graphic courtesy of FDA.

38. Disinfection of Water SystemsChlorination or addition of Chloramine to water systems is effective in killing most pathogens in the water system.Exception is Cryptosporidium, which is resistant to Chlorine at standard operating levels.Can be killed with hyperchlorination.Can be removed through filtration process.

39. Collaboration Key to PreventionAlthough the public health system will likely discover the initial contamination, much of the response will take place in the water utility arena.Decisions need to be made quickly about whether chlorination is effective against the suspected agent, whether the affected area of distribution can be isolated or whether a boil order should be issued. Will require a collaborative relationship between water utilities and public health!

40. Rules of Epi (Rules to Live By)Don’t eat or drink feces.Organisms may enter the water system at any time. It’s important to take steps to prevent illness such as disinfection of water sources. Never, ever….stop removing organisms from the water. WASH YOUR HANDS!

41. ReferencesCenters for Disease Control and Prevention. Current Waterborne Disease Burden Data & Gaps. https://www.cdc.gov/healthywater/burden/current-data.html.Gargano JW, Adam EA, Collier SA, Fullerton KE, Feinman SJ, Beach MJ. Mortality from selected diseases that can be transmitted by water — United States, 2003–2009. J Water Health. 2017;15(3):438-50.Adam EA, Collier SA, Fullerton KE, Gargano JW, Beach MJ. Prevalence and direct costs of emergency department visits and hospitalizations for 13 selected diseases that can be transmitted by water, United States. J Water Health. 2017;wh2017083.EPA. The history of drinking water treatment. [PDF - 4 pages] 2000.EPA. Basic information about disinfectants in drinking water: Chloramine, chlorine and chlorine dioxide. 2013.Greer A, Ng V, Fisman D. Climate change and infectious diseases in North America: the road ahead. CMAJ : Canadian Medical Association Journal. 2008;178(6):715-722. doi:10.1503/cmaj.081325.Auld H, MacIver D, Klaassen J. Heavy rainfall and waterborne disease outbreaks: the Walkerton example. J Toxicol Environ Health A. 2004 Oct 22-Nov 26;67(20-22):1879-87.

42. QUESTIONS?

43. Contact Info:Autumn Grim, MPH Missouri Department of Health & Senior ServicesSoutheast District Office-Cape GirardeauPhone: (573)290-5783 Email: autumn.grim@health.mo.gov