Beyond compliance: environmental health problem solving, interagency collaboration, and risk assessment to prevent waterborne disease outbreaks.

A systems approach to environmental health problem solving was used to investigate two waterborne norovirus outbreaks in Wyoming and can serve in the development of improved prevention strategies. An interagency collaboration to prevent waterborne disease involving local, state, and federal partners was designed to coordinate response to outbreak investigations. Improved risk assessment and reporting procedures were also integrated to ensure better availability of necessary data. Public health entities should implement sustainable intersectoral interventions to prevent waterborne disease that not only improve regulatory compliance but also have a positive impact on community health outcomes. Collaborative preventive health and water system protection activities should receive priority attention for implementation in state and local jurisdictions.

Case series: outbreak of conversion disorder among amish adolescent girls.

OBJECTIVE: Outbreak investigations are challenging in a cross-cultural context, and outbreaks of psychiatric disease are rare in any community. We investigated a cluster of unexplained debilitating illness among Amish girls. METHOD: We reviewed the medical records of cases, consulted with health care providers, performed active case finding, administered open-ended and structured interviews, and met with Amish community members. A case-patient was defined as a resident of the county who was bedridden for more than 3 weeks with otherwise unexplained systemic weakness and anorexia from January 2000 to February 2002. RESULTS: Five case-patients were identified. All were Amish girls aged 9 to 13 years. All five had debilitating voluntary motor deficits, anorexia, and weight loss. Four experienced neck weakness with inability to hold up their heads. Thorough medical evaluations failed to identify an organic etiology. All five patients met the diagnostic criteria for conversion disorder. Substantial social conflict within the Amish community preceded illness onset. Family behavioral interventions were recommended. Three months after the investigation, four of five patients demonstrated some improvement. CONCLUSIONS: Clinicians should be aware of the potential for outbreaks of psychogenic illness and work to address the challenges of developing effective intervention strategies, particularly in the cross-cultural context.

Waterborne outbreak of gastroenteritis associated with a norovirus.

The Wyoming Department of Health investigated an outbreak of acute gastroenteritis among persons who dined at a tourist saloon in central Wyoming during October 2001. Human caliciviruses (HuCVs) were suspected as the etiological agent of the outbreak based on the incubation period, duration of illness, and symptoms observed in ill patrons. A retrospective cohort study demonstrated that ill patrons were 4.5 times more likely to have exposure to drinking water and/or ice than nonill patrons. No food items were associated with illness. An environmental investigation gave evidence that the saloon's groundwater was contaminated with sewage. Water from the saloon's only well was processed for viruses. The processed water sample and stool samples collected from three ill patrons were analyzed by reverse transcription-PCR (RT-PCR) for the presence of HuCV. All positive RT-PCR results were confirmed by sequence and phylogenetic analyses of cloned RT-PCR products. A genogroup I, subtype 3, HuCV stain was found to be present in the well water sample and two stool samples. In addition, a genogroup II, subtype 6, strain was detected in one stool sample. The identification of the same HuCV strain in both the well water and stool samples strongly suggests a link between exposure to well water and the outbreak of gastroenteritis. The presence of a genogroup II, subtype 6, strain in one of the stool samples suggests that multiple HuCV strains may have been involved in this outbreak. The laboratory isolation of HuCV strains from outbreak-associated drinking water is relatively novel in the United States. This investigation outlines the procedure for virus isolation and illustrates the utility of RT-PCR for the identification of HuCV in large volumes of water and stool samples obtained during outbreaks of acute nonbacterial gastroenteritis.