Campers' diarrhea outbreak traced to water-sewage link.

From June through September 1979, diarrheal illness occurred in an estimated 1,850 persons who had camped at a private campground in Arizona. Illness occurred more frequently among campers at that campground than among those in the adjacent State park (P less than 0.0001). The same well served both the private and the State campgrounds as the source of drinking water, but that water was distributed to the two campgrounds through separate lines. Illness was significantly associated with drinking water at the campsite (P less than 0.0001), drinking larger quantities of campsite water (P less than 0.001), and camping on the southwest side of the campground (P less than 0.001). Samples of the water collected from the system during January through June contained no coliform bacteria. However, all those samples had been collected from the State park only. Of the 11 water samples submitted for bacteriological analyses during the summer, 3 had high levels of bacteria. Excavation of the water system uncovered a direct cross connection between the potable water system and a sewage-effluent irrigation system. This outbreak calls attention to the importance of designing, maintaining, and monitoring potable water systems properly, especially those proximate to wastewater re-use systems.

A three-state study of waterborne disease surveillance techniques.

For a two-year period, the states of Colorado, Vermont and Washington tested the effectiveness of ten surveillance methods for identifying waterborne disease. Nine were active surveillance methods, soliciting illness reports; one was passive, relying on voluntary disease reporting. One waterborne disease outbreak was identified through use of the nine active methods, while 14 were reported through the passive surveillance method. The presence of coliform bacteria during routine water testing was not related to illness in the community.

Case-control study of waterborne giardiasis in Reno, Nevada.

An outbreak of Giardia lamblia gastroenteritis occurred in Reno, Nevada, in 1982, during which 324 laboratory-confirmed infections were reported. During the outbreak, Reno was supplied in part by surface water that was chemically coagulated, settled, and chlorinated, but was not filtered. Giardia cysts were recovered from the water supply, and a beaver infected with Giardia was found in one of the reservoirs. A case-control study indicated that, during the outbreak but not afterwards, persons with giardiasis drank more municipal water than did controls. Corrective measures, which included removing the infected beaver and increasing the chlorine concentration, were followed by a rapid decrease in reports of giardiasis.

Cholera on a Gulf Coast oil rig.

A single case of severe diarrhea on a floating Texas oil rig was followed two days later by what proved to be the largest outbreak of cholera in the United States in over a century. After isolation of toxigenic Vibrio cholerae El Tor Inaba of the typical United States phage type from the index patient's stool, the ensuing investigation detected 14 additional cases of cholera and one asymptomatic infection serologically. Infection was associated with eating rice on the oil rig on a particular day (P = 0.03) when an open valve permitted the rig's drinking-water system to be contaminated by canal water containing sewage (including that from the index patient) discharged from the rig. The rice had been rinsed in the contaminated water after cooking, and before being served it had been maintained at a temperature that allows V. cholerae 01 to multiply. Toxigenic V. cholerae 01 is persisting in the United States, and large common-source outbreaks of cholera can occur if proper sanitation is not maintained.

An outbreak of waterborne giardiasis associated with heavy water runoff due to warm weather and volcanic ashfall.

From mid-June through early August 1980, an outbreak of gastrointestinal illness in Red Lodge, Montana affected approximately 780 persons, as estimated from attack rates of 33 per cent and 15 per cent in urban and rural residents, respectively. Giardia lamblia was identified in stool specimens from 51 per cent of 47 persons with a history of untreated gastrointestinal illness and in 13 per cent of 24 specimens from asymptomatic persons (p = .00045, Fisher's Exact Test). The epidemic curve was bimodal with peaks in mid-June and mid-July. Each peak occurred about three weeks after an episode of very heavy water runoff resulting from warm sunny weather and snow darkened by ashfall from the Mt. St. Helens volcanic eruption of May 18, 1980. Unfiltered and inadequately chlorinated surface water was supplied by the city water system, which was implicated as the vehicle of transmission in the outbreak. Water systems providing unfiltered surface water are more likely to become contaminated during periods of heavy water runoff.

Waterborne outbreak control: which disinfectant?

Drinking water disinfection was shown to be an important public health measure around the turn of the century. In the United States, it was perhaps the single most important factor in controlling typhoid fever, a waterborne disease that was rampant throughout the world during the last century. It may also be assumed that disinfection was important in limiting the number of cases of other diseases known to be capable of waterborne transmission, i.e., cholera, amebiasis, shigellosis, salmonellosis, and hepatitis A. Even though modern treatment has eliminated water as a major vehicle of infectious disease transmission, outbreaks still occur. In fact, the annual number has been increasing since 1966. Interruption in chlorination or failure to achieve adequate levels of chlorine residual is the most often identified deficiency of the involved water supplies. This finding indicates that waterborne microbial pathogens remain as a potential health threat and underscores the importance of disinfection. From the outset, chlorination has been the drinking water disinfectant of choice in the country. Numerous studies have demonstrated its ability to inactivate bacterial, viral, and protozoal pathogens when applied under proper conditions. However, the finding that chlorinated organics that are potentially carcinogenic are formed has prompted an evaluation of alternative disinfectants. The viable alternatives to chlorine currently under consideration for widespread use are ozone, chlorine dioxide, and chloramines. In terms of biocidal efficiency, ozone is the most potent of the three. Chlorine dioxide is about the equivalent of free chlorine in the hypochlorous acid form but much more efficient than the hypochlorite form of free chlorine. The chloramines are weaker biocides than hypochlorite. Although this general order of ranking of efficiency holds for diverse types of microorganisms, quantitative comparisons vary with different microorganisms and experimental conditions.

Gastroenteritis due to Norwalk virus: an outbreak associated with a municipal water system.

An outbreak of gastroenteritis lasting for one week in August 1980 affected approximately 1,500 persons in a community in northern Georgia. Investigation included a telephone survey of the community, a survey of textile plant employees and junior high and high school students and staff, and a neighborhood door-to-door survey. An association between gastrointestinal illness and consumption of drinking water was shown for community residents, students, and school staff. Attack rates (0-68%) determined in 10 neighborhoods increased significantly (P less than 0.001) with proximity to a textile plant, the site of one of two known cross-connections between an industrial water system (which contained fecal coliform bacteria) and the community water system. A fourfold rise in titer of antibody to Norwalk virus was found in 12 of 19 serum pairs from patients. Norwalk virus illness associated with drinking water from a large municipal water system has not been documented previously. Norwalk virus may be an important cause of waterborne morbidity in the United States.

Waterborne giardiasis: a communitywide outbreak of disease and a high rate of asymptomatic infection.

A communitywide outbreak of gastrointestinal illness due to Giardia lamblia infection occurred in the city of Berlin, New Hampshire, during April and May 1977. The clinical, epidemiologic, and laboratory aspects of this outbreak are described here. In 213 predominantly symptomatic cases of G. lamblia infection diagnosed at a local hospital laboratory in a 6-week period, illness was characterized by prolonged diarrhea (median duration 10 days) and 13% of symptomatic infections required hospitalization. Treatment with either quinacrine or metronidazole was generally followed by symptomatic improvement. A communitywide survey of the city residents revealed that the majority (76%) of G. lamblia infections occurring during the epidemic period were asymptomatic and ran a self-limited course without treatment. No significant secondary, person-to-person spread occurred and no enteric pathogens other than G. lamblia were implicated. Water was epidemiologically implicated as the most likely source of infection with Giardia cysts being demonstrated in samples of treated water as well as raw source water. Evidence supported the occurrence of two simultaneous outbreaks in this city which is supplied by two largely independent water supply systems. Inspection of the two water treatment facilities revealed several defects which permitted untreated (raw) water to mix with treated water. Human or beaver could have been responsible for contaminating source water with Giardia in this outbreak. A marked reduction in both clinical and subclinical giardiasis was apparent two months after onset of the outbreak, apparently as a result of measures applied to interrupt waterborne transmission of Giardia.

Composition and biological properties of lipopolysaccharides isolated from Schizothrix calcicola (Ag.) Gomont (Cyanobacteria).

The most common cyanobacterium contaminating drinking water systems in southwestern Pennsylvania is Schizothrix calcicola. Lipoplysaccharides (LPS) were isolated from this species by hot phenol-water extraction. The polysaccharide moiety was composed of glucosamine, galactose, glucose, mannose, xylose and rhamnose. The lipid A part contained beta-hydroxylauric, myristic, pentadecanoic, palmitic, beta-hydroxypalmitic, stearic, oleic, and linoleic acids. In contrast to many LPS isolated from Enterobacteriaceae, the dominant component was not beta-hydroxymyristic but beta-hydroxypalmitic acid. The LPS induced Limulus lysate gelation and Schwartzman reaction but was nontoxic to mice. The identity of LPS was verified by alkali and lysozyme treatment. The results suggest that S. calcicola is one of the principal sources of endotoxins in water systems using open finished-water reservoirs.