Outbreaks van ziekte via drinkwater

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1 Outbreaks van ziekte via drinkwater Gertjan Medema hoogleraar Water & Gezondheid Delft University of Technology Challenge the future

2 Cryptosporidium 2

3 Cryptosporidium 3

4 Drink water = transmissie route Ann Intern Med Dec;103(6 ( Pt 1)): A waterborne outbreak of cryptosporidiosis in normal hosts. D'Antonio RG, Winn RE, Taylor JP, Gustafson TL, Current WL, Rhodes MM, Gary GW Jr, Zajac RA. In July 1984, an outbreak of gastroenteritis occurred in a suburban community in Texas. A random telephone survey of 100 of 1791 households in the community identified an attack rate of 34%. The outbreak was traced to contamination of the community water supply, an artesian well. Fecal coliforms were identified in untreated drinking water from the well during July. Stool examinations and serologic tests identified Cryptosporidium as the etiologic agent. Cryptosporidium should be added to the list of waterborne organisms capable of causing outbreaks of gastroenteritis. 4

5 E.coli is geen goede indicator Epidemiol Infect Dec;103(3): An outbreak of waterborne cryptosporidiosis caused by post-treatment contamination. Smith HV, Patterson WJ, Hardie R, Greene LA, Benton C, Tulloch W, Gilmour RA, Girdwood RW, Sharp JC, Forbes GI. Department of Bacteriology, Stobhill General Hospital, Glasgow. An outbreak of waterborne cryptosporidiosis affecting 27 persons, diagnosed stool positive, occurred in Ayrshire in April Twenty-one in 27 confirmed cases required some form of fluid replacement therapy. Local general practitioners indicated a two- to fivefold increase in diarrhoeal disease during the outbreak, and following enquiries made by Environmental Health Officers it became apparent that many hundreds of people had suffered a diarrhoeal illness at that time. Cryptosporidium spp. oocysts were detected in the treated chlorinated water supply system, in the absence of faecal bacterial indicators. Oocyst contamination of a break-pressure tank containing final water for distribution was the cause of this waterborne outbreak. An irregular seepage of oocyst-containing water, which increased during heavy rains, was the cause of the break-pressure tank contamination, rather than a failure of the water-treatment processes. The waterborne route should be considered when clusters of cryptosporidiosis-associated with potable water occur. Waterborne cryptosporidiosis can occur in the absence of other faecal indicators of contamination. 5

6 Multiple barriers? Chloor niet effectief: one down Speciaal relevant voor watersystemen zonder filtratie Photo: Evides Photo: Melbourne Water 6

7 Crypto kan door suboptimale conventionele zuivering breken N Engl J Med Jul 21;331(3): A massive outbreak in Milwaukee of cryptosporidium infection transmitted through the public water supply. Mac Kenzie WR, Hoxie NJ, Proctor ME, Gradus MS, Blair KA, Peterson DE, Kazmierczak JJ, Addiss DG, Fox KR, Rose JB, et al. Wisconsin Division of Health, Bureau of Public Health, Madison BACKGROUND. Early in the spring of 1993 there was a widespread outbreak of acute watery diarrhea among the residents of Milwaukee. METHODS. We investigated the two Milwaukee water-treatment plants, gathered data from clinical laboratories on the results of tests for enteric pathogens, and examined ice made during the time of the outbreak for cryptosporidium oocysts. We surveyed residents with confirmed cryptosporidium infection and a sample of those with acute watery diarrhea consistent with cryptosporidium infection. To estimate the magnitude of the outbreak, we also conducted a survey using randomly selected telephone numbers in Milwaukee and four surrounding counties. RESULTS. There were marked increases in the turbidity of treated water at the city's southern water-treatment plant from March 23 until April 9, when the plant was shut down. Cryptosporidium oocysts were identified in water from ice made in southern Milwaukee during these weeks. The rates of isolation of other enteric pathogens remained stable, but there was more than a 100-fold increase in the rate of isolation of cryptosporidium. The median duration of illness was 9 days (range, 1 to 55). The median maximal number of stools per day was 12 (range, 1 to 90). Among 285 people surveyed who had laboratory-confirmed cryptosporidiosis, the clinical manifestations included watery diarrhea (in 93 percent), abdominal cramps (in 84 percent), fever (in 57 percent), and vomiting (in 48 percent). We estimate that 403,000 people had watery diarrhea attributable to this outbreak. CONCLUSIONS. This massive outbreak of watery diarrhea was caused by cryptosporidium oocysts that passed through the filtration system of one of the city's water-treatment plants. Water-quality standards and the testing of patients for cryptosporidium were not adequate to detect this outbreak. 7

8 Cryptosporidium outbreak April

9 Troebelheid drinkwater Milwaukee 9

10 Milwaukee 10

11 Milwaukee 11

12 Piek afvoer na hevige regen 12

13 Milwaukee outbreak mensen ziek 4400 in ziekenhuis doden $ 96 miljoen 1/3 gezondheidszorg 2/3 verloren arbeid 13

14 Milwaukee uitbraak: cascade Voldoende berging in riool Hevige regenval Overstort riool in rivier + hoge vuillast rivier Inlaat drinkwater in vuilpluim Onervaren met nieuwe coagulatie Chloordosering heeft geen effect op Cryptosporidium Keuze inlaatlocatie Halve stad ziek Meerdere barrières 14

15 Multiple barriers? Chloor niet effectief: one down en optimaliseren coagulatie/filtratie Speciaal relevant voor watersystemen zonder filtratie: bronbescherming Photo: Evides Photo: Melbourne Water 15

16 UV effectief tegen Cryptosporidium Eerdere studies met in vitro assays: 0.2 log at 15 mj/cm 2 Met infectiviteitsassay: 3 log at 15 mj/cm 2 Photo: Hannovia 16

17 UV als nieuwe barriere 17

18 Parkwijk, Leidsche Rijn, Utrecht 18

19 Leidsche Rijn, Utrecht 19

20 Gebeurtenissen 3 dec smaakklachten vanuit 2 huishoudens Waterbedrijf heeft monsters genomen 5 dec verdachte coli: kookadvies 900 huishoudens 6 dec nog 100 huishoudens 6 dec spuien, druktesten Kruisverbinding huishoudwaternet en drinkwaternet 20

21 Onderzoek (Gezondheidsinstellingen) Naar schatting 200 mensen ziek (darminfecties) Niet duidelijk welke ziekteverwekker Niet duidelijk welke ziekteverwekker in water Norovirus?? 21

22 Nieuw huishoudwater leidingnet in Noord 2 Sep Dec ,3,4 Dec

23 Wet van Murphy Jan 2002 nog een smaakklacht Geleidbaarheidstest: drinkwater = huishoudwater Kruisverbinding dit huishouden gedurende 17 maanden Nader onderzeok naar alle aansluitingen: 4 huishoudens met kruisverbinding Waterbedrijf heeft beslotent e stoppen met huishoudwater Alle waterbedrijven volgden VROM verbied grootschalige huishoudwaterlevering 23

24 Shit happens! 24

25 58 th Convention of Legionnaires, Philadelphia 1976 Juli Legionnaires en familie 25

26 Sequence of events July Legionairs that had attended meeting in July in hotel in Philadelphia came down with high fever and pneumonia July 27 First patient died August legionairs ill, 20 died End 221 cases, 34 dead 26

27 Whodunnit? Pneumonia: January 1976 influenza epidemic in US: influenza? Legionnaires: Poisonning? Biowarfare: - New killer bug that escaped? 27

28 Whidunnit? 28

29 Investigations - Clinical/post-mortem: - no known pneumonia bacteria, - no influenza or other virus, - no poisons, - no metals - no smoking gun - Epidemiology: - Questionnaires looking into all possible common sources - Visit to convention in Bellevue hotel - No clear source - Why some and others not? 29

Christmas, a time for insult and looking back McDade originally examined patient specimens to rule out Q-fever (pneumonia, but cattle related) - Inoculate guinea pigs, bacteria in spleen, transfer to

30 Christmas, a time for insult and looking back McDade originally examined patient specimens to rule out Q-fever (pneumonia, but cattle related) - Inoculate guinea pigs, bacteria in spleen, transfer to embryonated eggs: no rickettsiae Re-examined specimens - Now transfer to eggs without antibiotics: bacteria growing (evidence 1) - Infect guinea pigs: fever (evidence 2) - Same bacterium from several patients (evidence 3) - Antibodies in blood from patients (evidence 4) This 1977 image shows the CDC s Joseph E. McDade, PhD (left), and Charles C. Shepard, MD (right), working with a microscope in the CDC s leprosy and rickettsia labs. On Jan. 14, 1977, the director of the CDC s laboratory division, Shepard and microbiologist McDade isolated the agent that had caused the legionnaires outbreak. 30

31 Honor our fallen comrades Legionella 31

32 Legionnaires disease Severe pneumonia (Legionellosis) Mild pneumonia (Pontiac fever) Legionella pneumophila O1 Treatment with antibiotics - erythromycin, levaquin or azithromycin 32

33 Where did it come from? Never proven Epidemiology suggested the lobby airconditioning system was the cause Just cleaned before investigated, no Legionella found (poor methods) 33

34 Bovenkarspel 1999 Flower exhibition 34

35 Outbreak of legionellosis 35

36 Legionella? Water systems! 36

37 Suspects! Whirlpools Fountains Humidifiers Irrigation 37

38 Sampling mains All samples negative with culture methods and PCR 38

39 Sampling water systems Legionella pneumophila found Whirlpool hall 4 (culture+pcr) Humidifier hall 8 Whirlpool hall 3 39

40 AFLP fingerprinting of patient and water isolates 40

41 Time to grow?! Delay between start of exhibition and acquiring disease 41

42 Large impact 242 cases of serious pneumonia 28 died Many cases still experiencing disabilities today Service in memory of victims of Legionella outbreak Bovenkarspel where relatives are addressed by minister Borst (Public Health) 42

43 43

44 Legionellosis in the Netherlands 44

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