Tag Archives: Centers for Disease Control (CDC)

Waterborne Disease Associated with US Environmental Waters, 2013-2014

McClung RP, Roth DM, Vigar M, Roberts VA, Kahler AM, Cooley LA, Hilborn ED, Wade TJ, Fullerton KE, Yoder JS, Hill VR. Waterborne Disease Outbreaks Associated With Environmental and Undetermined Exposures to Water – United States, 2013-2014. MMWR Morb Mortal Wkly Rep. 2017 Nov 10;66(44):1222-1225. doi: 10.15585/mmwr.mm6644a4.

Waterborne disease outbreaks in the United States are associated with a wide variety of water exposures and are reported annually to CDC on a voluntary basis by state and territorial health departments through the National Outbreak Reporting System (NORS). A majority of outbreaks arise from exposure to drinking water (1) or recreational water (2), whereas others are caused by an environmental exposure to water or an undetermined exposure to water. During 2013-2014, 15 outbreaks associated with an environmental exposure to water and 12 outbreaks with an undetermined exposure to water were reported, resulting in at least 289 cases of illness, 108 hospitalizations, and 17 deaths. Legionella was responsible for 63% of the outbreaks, 94% of hospitalizations, and all deaths. Outbreaks were also caused by Cryptosporidium, Pseudomonas, and Giardia, including six outbreaks of giardiasis caused by ingestion of water from a river, stream, or spring. Water management programs can effectively prevent outbreaks caused by environmental exposure to water from human-made water systems, while proper point-of-use treatment of water can prevent outbreaks caused by ingestion of water from natural water systems.

Waterborne Disease Outbreaks Associated with US Drinking Water, 2013-2014

Benedict KM, Reses H, Vigar M, Roth DM, Roberts VA, Mattioli M, Cooley LA, Hilborn ED, Wade TJ, Fullerton KE, Yoder JS, Hill VR. Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water – United States, 2013-2014. MMWR Morb Mortal Wkly Rep. 2017 Nov 10;66(44):1216-1221. doi: 10.15585/mmwr.mm6644a3.

Provision of safe water in the United States is vital to protecting public health (1). Public health agencies in the U.S. states and territories* report information on waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS) (https://www.cdc.gov/healthywater/surveillance/index.html). During 2013-2014, 42 drinking water-associated† outbreaks were reported, accounting for at least 1,006 cases of illness, 124 hospitalizations, and 13 deaths. Legionella was associated with 57% of these outbreaks and all of the deaths. Sixty-nine percent of the reported illnesses occurred in four outbreaks in which the etiology was determined to be either a chemical or toxin or the parasite Cryptosporidium. Drinking water contamination events can cause disruptions in water service, large impacts on public health, and persistent community concern about drinking water quality. Effective water treatment and regulations can protect public drinking water supplies in the United States, and rapid detection, identification of the cause, and response to illness reports can reduce the transmission of infectious pathogens and harmful chemicals and toxins.

CDC: Dental Caries in Rural Alaska Native Children — Alaska, 2008

This study concludes that tooth decay is higher in rural Alaska. Click here for a news article discussing this study by the State of Alaska and CDC.

The study itself (click here) states:

“Dental caries severity was greater in nonfluoridated villages. Children from nonfluoridated villages had 1.2–2.9 times higher mean dft or DMFT than children from fluoridated villages and 1.2–3.1 times the mean number of decayed teeth. Children from the Alaska region had 1.5–4.5 times the number of dft or DMFT than same-aged U.S. children and 1.6–9.0 times the number of decayed teeth. On age-adjusted bivariate analysis, only lack of water fluoridation, increased soda pop consumption, and infrequent brushing of teeth were significantly associated with dental caries severity in primary and permanent teeth (all p-values <0.05).”

Lack of water fluoridation is implicated,

“Dental caries severity was greater in nonfluoridated villages. Children from nonfluoridated villages had 1.2–2.9 times higher mean dft or DMFT than children from fluoridated villages and 1.2–3.1 times the mean number of decayed teeth. Children from the Alaska region had 1.5–4.5 times the number of dft or DMFT than same-aged U.S. children and 1.6–9.0 times the number of decayed teeth. On age-adjusted bivariate analysis, only lack of water fluoridation, increased soda pop consumption, and infrequent brushing of teeth were significantly associated with dental caries severity in primary and permanent teeth (all p-values <0.05).”

Press Spin: CIDRAP spins CDC data

The CDC data analysis on drinking water and recreational water posted yesterday on this blog and available directly from CDC is a straight forward analysis of data from 2007 to 2008….which does not represent today.  Yet the CIDRAP has generated an alarmist headline…..would you think this university center is spinning this in self-interest? Why would any agency issue a press release giving the impression that 3 and 4 year old data has any relevance to today?  Click here

CDC: Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water—United States, 2007–2008

Brunkard, J.M. et al. 2011. Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water–United States, 2007-2008. MMWR / September 23, 2011 / Vol. 60 / No. 12

Click here for the full report (free).

Abstract

Problem/Condition:  Since 1971, CDC, the Environmental Protection Agency (EPA), and the Council of State and Territorial Epidemiologists have collaborated on the Waterborne Disease and Outbreak Surveillance System (WBDOSS) for collecting and reporting data related to occurrences and causes of waterborne disease outbreaks associated with drinking water. This surveillance system is the primary source of data concerning the scope and health effects of waterborne disease outbreaks in the United States.

Reporting Period: Data presented summarize 48 outbreaks that occurred during January 2007–December 2008 and 70 previously unreported outbreaks.

Description of System: WBDOSS includes data on outbreaks associated with drinking water, recreational water, water not intended for drinking (WNID) (excluding recreational water), and water use of unknown intent (WUI). Public health agencies in the states, U.S. territories, localities, and Freely Associated States are primarily responsible for detecting and investigating outbreaks and reporting them voluntarily to CDC by a standard form. Only data on outbreaks associated with drinking water, WNID (excluding recreational water), and WUI are summarized in this report. Outbreaks associated with recreational water are reported separately.

Results: A total of 24 states and Puerto Rico reported 48 outbreaks that occurred during 2007–2008. Of these 48 outbreaks, 36 were associated with drinking water, eight with WNID, and four with WUI. The 36 drinking water–associated outbreaks caused illness among at least 4,128 persons and were linked to three deaths. Etiologic agents were identified in 32 (88.9%) of the 36 drinking water–associated outbreaks; 21 (58.3%) outbreaks were associated with bacteria, five (13.9%) with viruses, three (8.3%) with parasites, one (2.8%) with a chemical, one (2.8%) with both bacteria and viruses, and one (2.8%) with both bacteria and parasites. Four outbreaks (11.1%) had unidentified etiologies. Of the 36 drinking water–associated outbreaks, 22 (61.1%) were outbreaks of acute gastrointestinal illness (AGI), 12 (33.3%) were outbreaks of acute respiratory illness (ARI), one (2.8%) was an outbreak associated with skin irritation, and one (2.8%) was an outbreak of hepatitis. All outbreaks of ARI were caused by Legionella spp. A total of 37 deficiencies were identified in the 36 outbreaks associated with drinking water. Of the 37 deficiencies, 22 (59.5%) involved contamination at or in the source water, treatment facility, or distribution system; 13 (35.1%) occurred at points not under the jurisdiction of a water utility; and two (5.4%) had unknown/insufficient deficiency information. Among the 21 outbreaks associated with source water, treatment, or distribution system deficiencies, 13 (61.9%) were associated with untreated ground water, six (28.6%) with treatment deficiencies, one (4.8%) with a distribution system deficiency, and one (4.8%) with both a treatment and a distribution system deficiency. No outbreaks were associated with untreated surface water. Of the 21 outbreaks, 16 (76.2%) occurred in public water systems (drinking water systems under the jurisdiction of EPA regulations and water utility management), and five (23.8%) outbreaks occurred in individual systems (all of which were associated with untreated ground water). Among the 13 outbreaks with deficiencies not under the jurisdiction of a water system, 12 (92.3%) were associated with the growth of Legionella spp. in the drinking water system, and one (7.7%) was associated with a plumbing deficiency. In the two outbreaks with unknown deficiencies, one was associated with a public water supply, and the other was associated with commercially bottled water. The 70 previously unreported outbreaks included 69 Legionella outbreaks during 1973–2000 that were not reportable previously to WBDOSS and one previously unreported outbreak from 2002.

Interpretation: More than half of the drinking water–associated outbreaks reported during the 2007–2008 surveillance period were associated with untreated or inadequately treated ground water, indicating that contamination of ground water remains a public health problem. The majority of these outbreaks occurred in public water systems that are subject to EPA’s new Ground Water Rule (GWR), which requires the majority of community water systems to complete initial sanitary surveys by 2012. The GWR focuses on identification of deficiencies, protection of wells and springs from contamination, and providing disinfection when necessary to protect against bacterial and viral agents. In addition, several drinking water–associated outbreaks that were related to contaminated ground water appeared to occur in systems that were potentially under the influence of surface water. Future efforts to collect data systematically on contributing factors associated with drinking water outbreaks and deficiencies, including identification of ground water under the direct influence of surface water and the criteria used for their classification, would be useful to better assess risks associated with ground water.

During 2007–2008, Legionella was the most frequently reported etiology among drinking water–associated outbreaks, following the pattern observed since it was first included in WBDOSS in 2001. However, six (50%) of the 12 drinking water–associated Legionella outbreaks were reported from one state, highlighting the substantial variance in outbreak detection and reporting across states and territories. The addition of published and CDC-investigated legionellosis outbreaks to the WBDOSS database clarifies that Legionella is not a new public health issue. During 2009, Legionella was added to EPA’s Contaminant Candidate List for the first time.

Public Health Actions: CDC and EPA use WBDOSS surveillance data to identify the types of etiologic agents, deficiencies, water systems, and sources associated with waterborne disease outbreaks and to evaluate the adequacy of current technologies and practices for providing safe drinking water. Surveillance data also are used to establish research priorities, which can lead to improved water quality regulation development. Approximately two thirds of the outbreaks associated with untreated ground water reported during the 2007–2008 surveillance period occurred in public water systems. When fully implemented, the GWR that was promulgated in 2006 is expected to result in decreases in ground water outbreaks, similar to the decreases observed in surface water outbreaks after enactment of the Surface Water Treatment Rule in 1974 and its subsequent amendments. One third of drinking water–associated outbreaks occurred in building premise plumbing systems outside the jurisdiction of water utility management and EPA regulations; Legionella spp. accounted for >90% of these outbreaks, indicating that greater attention is needed to reduce the risk for legionellosis in building plumbing systems. Finally, a large communitywide drinking water outbreak occurred in 2008 in a public water system associated with a distribution system deficiency, underscoring the importance of maintaining and upgrading drinking water distribution system infrastructure to provide safe water and protect public health.Reporting Period: Data presented summarize 48 outbreaks that occurred during January 2007–December 2008 and 70 previously unreported outbreaks.

Description of System: WBDOSS includes data on outbreaks associated with drinking water, recreational water, water not intended for drinking (WNID) (excluding recreational water), and water use of unknown intent (WUI). Public health agencies in the states, U.S. territories, localities, and Freely Associated States are primarily responsible for detecting and investigating outbreaks and reporting them voluntarily to CDC by a standard form. Only data on outbreaks associated with drinking water, WNID (excluding recreational water), and WUI are summarized in this report. Outbreaks associated with recreational water are reported separately.

Results: A total of 24 states and Puerto Rico reported 48 outbreaks that occurred during 2007–2008. Of these 48 outbreaks, 36 were associated with drinking water, eight with WNID, and four with WUI. The 36 drinking water–associated outbreaks caused illness among at least 4,128 persons and were linked to three deaths. Etiologic agents were identified in 32 (88.9%) of the 36 drinking water–associated outbreaks; 21 (58.3%) outbreaks were associated with bacteria, five (13.9%) with viruses, three (8.3%) with parasites, one (2.8%) with a chemical, one (2.8%) with both bacteria and viruses, and one (2.8%) with both bacteria and parasites. Four outbreaks (11.1%) had unidentified etiologies. Of the 36 drinking water–associated outbreaks, 22 (61.1%) were outbreaks of acute gastrointestinal illness (AGI), 12 (33.3%) were outbreaks of acute respiratory illness (ARI), one (2.8%) was an outbreak associated with skin irritation, and one (2.8%) was an outbreak of hepatitis. All outbreaks of ARI were caused by Legionella

A total of 37 deficiencies were identified in the 36 outbreaks associated with drinking water. Of the 37 deficiencies, 22 (59.5%) involved contamination at or in the source water, treatment facility, or distribution system; 13 (35.1%) occurred at points not under the jurisdiction of a water utility; and two (5.4%) had unknown/insufficient deficiency information. Among the 21 outbreaks associated with source water, treatment, or distribution system deficiencies, 13 (61.9%) were associated with untreated ground water, six (28.6%) with treatment deficiencies, one (4.8%) with a distribution system deficiency, and one (4.8%) with both a treatment and a distribution system deficiency. No outbreaks were associated with untreated surface water. Of the 21 outbreaks, 16 (76.2%) occurred in public water systems (drinking water systems under the jurisdiction of EPA regulations and water utility management), and five (23.8%) outbreaks occurred in individual systems (all of which were associated with untreated ground water). Among the 13 outbreaks with deficiencies not under the jurisdiction of a water system, 12 (92.3%) were associated with the growth of Legionella spp. in the drinking water system, and one (7.7%) was associated with a plumbing deficiency. In the two outbreaks with unknown deficiencies, one was associated with a public water supply, and the other was associated with commercially bottled water. The 70 previously unreported outbreaks included 69 Legionella outbreaks during 1973–2000 that were not reportable previously to WBDOSS and one previously unreported outbreak from 2002.

Interpretation: More than half of the drinking water–associated outbreaks reported during the 2007–2008 surveillance period were associated with untreated or inadequately treated ground water, indicating that contamination of ground water remains a public health problem. The majority of these outbreaks occurred in public water systems that are subject to EPA’s new Ground Water Rule (GWR), which requires the majority of community water systems to complete initial sanitary surveys by 2012. The GWR focuses on identification of deficiencies, protection of wells and springs from contamination, and providing disinfection when necessary to protect against bacterial and viral agents. In addition, several drinking water–associated outbreaks that were related to contaminated ground water appeared to occur in systems that were potentially under the influence of surface water. Future efforts to collect data systematically on contributing factors associated with drinking water outbreaks and deficiencies, including identification of ground water under the direct influence of surface water and the criteria used for their classification, would be useful to better assess risks associated with ground water.

During 2007–2008, Legionella was the most frequently reported etiology among drinking water–associated outbreaks, following the pattern observed since it was first included in WBDOSS in 2001. However, six (50%) of the 12 drinking water–associated Legionella outbreaks were reported from one state, highlighting the substantial variance in outbreak detection and reporting across states and territories. The addition of published and CDC-investigated legionellosis outbreaks to the WBDOSS database clarifies that Legionella is not a new public health issue. During 2009, Legionella was added to EPA’s Contaminant Candidate List for the first time.

Public Health Actions: CDC and EPA use WBDOSS surveillance data to identify the types of etiologic agents, deficiencies, water systems, and sources associated with waterborne disease outbreaks and to evaluate the adequacy of current technologies and practices for providing safe drinking water. Surveillance data also are used to establish research priorities, which can lead to improved water quality regulation development. Approximately two thirds of the outbreaks associated with untreated ground water reported during the 2007–2008 surveillance period occurred in public water systems. When fully implemented, the GWR that was promulgated in 2006 is expected to result in decreases in ground water outbreaks, similar to the decreases observed in surface water outbreaks after enactment of the Surface Water Treatment Rule in 1974 and its subsequent amendments. One third of drinking water–associated outbreaks occurred in building premise plumbing systems outside the jurisdiction of water utility management and EPA regulations; Legionella spp. accounted for >90% of these outbreaks, indicating that greater attention is needed to reduce the risk for legionellosis in building plumbing systems. Finally, a large communitywide drinking water outbreak occurred in 2008 in a public water system associated with a distribution system deficiency, underscoring the importance of maintaining and upgrading drinking water distribution system infrastructure to provide safe water and protect public health.

 

CDC Optimal Fluoride Level Proposed

The Centers for Disease Control and Prevention (CDC) proposed on January 7, 2011 that all community water systems adjust the amount of fluoride to 0.7 mg/L to achieve an optimal fluoride level.  The CDC believes the optimal level is the concentration that provides the best balance of protection from dental caries while limiting the risk of dental fluorosis.

The CDC proposal was published in the Federal Register and the public comment period has closed.  Final action has not yet been taken to adopt this optimal level.

Click here for the January 7, 2011, proposal notice.

Click here for the CDC oral health web pages and additional information on fluoride.