WaterborneDisease Measures

1
Waterborne Disease and Outbreak Surveillance
Sharon Roy, MD MPH
Division of
Parasitic Diseases
National Center for
Zoonotic, Vector-borne Enteric Diseases
Centers for
Disease Control and Prevention
June 14, 2007
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Waterborne Disease and Outbreak Surveillance
System (WBDOSS)

• Annual solicitation of standardized reports from
  state and territorial health departments

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Deficiency

• Antecedent event or situation that results in
  exposure of persons to a disease-causing agent or
  agents
• One deficiency per outbreak
• Deficiency without which outbreak would not have
  occurred

4
Historical Drinking Water System Deficiencies

• Untreated surface water
• Untreated groundwater
• Treatment deficiency
• Distribution system deficiency
• Unknown or miscellaneous deficiency
• Contaminated bottled water
• Source water not intended for drinking

5
Updating the Waterborne Disease and Outbreak
Surveillance System

• Transitioning from paper to electronic reporting
• Expanding historical 5-category deficiency
  classification system
• Expanding list of factors contributing to
  drinking water contamination

6
TCR / Distribution System Questions

• Distribution system deficiencies versus
  source/treatment deficiencies
• Distribution system deficiencies over time

7
Drinking Water Outbreaks in Public and Private
Water Systems by Deficiency, United States
19782002 (N563)
SWTR/TCR 1989
SWTR/TCR 1989
DRAFT - Preliminary Data
SWTR/TCR 1989
SWTR/TCR 1989
Excludes outbreaks of Legionnaires disease
8
Drinking Water Outbreaks in Public Water Systems
With Deficiencies 14, United States 19782002
(N401)
Untreated Surface Water (Deficiency 1)
Untreated Ground Water (Deficiency 2)
DRAFT - Preliminary Data
Treatment Deficiency (Deficiency 3)
Distribution System Deficiency (Deficiency 4)
Excludes outbreaks of Legionnaires Disease
9
Drinking Water Outbreaks in Public Water Systems
With Deficiencies 14, United States 19782002
(N401)
Distribution System Deficiency (Deficiency 4)
All Public Systems
Distribution System Deficiency in Community
Systems (Deficiency 4)
DRAFT - Preliminary Data
Distribution System Deficiency in Non-community
Systems (Deficiency 4)
Excludes outbreaks of Legionnaires Disease
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Drinking Water Outbreaks in Public Water Systems
With Deficiencies 14, United States 19782002
(N401)
DRAFT - Preliminary Data
Excludes outbreaks of Legionnaires Disease
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Drinking Water Outbreaks in Public Water Systems
With Deficiencies 14, United States 19782002
(N401)
Deficiencies 1-4 All Water Sources
Surface Water Systems Def 1,3,4
DRAFT - Preliminary Data
Ground Water Systems Def 2,3,4
Excludes outbreaks of Legionnaires Disease
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Drinking Water Outbreaks in Public Water Systems
With Deficiencies 14, United States 19782002
(N401)
Deficiencies 1-4 All Water Sources
Surface Water Systems Def 1,3,4
DRAFT - Preliminary Data
Ground Water Systems Def 2,3,4
Excludes outbreaks of Legionnaires Disease
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Drinking Water Outbreaks in Public Water Systems
With Deficiencies 14, United States 19782002
(N401)
Treatment Deficiency (Deficiency 3) All Water
Sources
Treatment Deficiency with Surface Water
(Deficiency 3)
DRAFT - Preliminary Data
Treatment Deficiency with Ground Water
(Deficiency 3)
Excludes outbreaks of Legionnaires Disease
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Drinking Water Outbreaks in Public Water Systems
With Deficiencies 14, United States 19782002
(N401)
Untreated Surface Water (Deficiency 1)
Untreated Ground Water (Deficiency 2)
DRAFT - Preliminary Data
Excludes outbreaks of Legionnaires Disease
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Untreated Surface Water (Deficiency 1)
Untreated Ground Water (Deficiency 2)
All Public Systems
DRAFT - Preliminary Data
Community Systems
Non-community Systems
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Drinking Water Outbreaks in Public Water Systems
With Deficiencies 14, United States 19782002
(N401)
DRAFT - Preliminary Data
Excludes outbreaks of Legionnaires Disease
17
Drinking Water Outbreaks in Public Water Systems
With Deficiencies 14, United States 19782002
(N401)
DRAFT - Preliminary Data
Excludes outbreaks of Legionnaires Disease
18
TCR / Distribution System Questions

• Distribution system deficiencies within and
  outside utility jurisdiction

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New WBDO Drinking Water Deficiencies

• 1. Untreated surface water intended for
  drinking
• 2. Untreated ground water intended for
  drinking
• 3. Treatment deficiency
• 4. Distribution system deficiency, including
  storage

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New WBDO Drinking Water Deficiencies

• 5. Legionella spp. in water system
• 6. Plumbing system deficiency after water meter
  or property line
• 7. Deficiency in building/home-specific water
  treatment
• 8. Deficiency or contamination of
  equipment/devices using or distributing water
• 9. Contamination during commercial bottling
• 10. Contamination during shipping, hauling, or
  storage
• 11. Contamination at point of use

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Original Deficiency 4 Distribution System

• Pipes and storage infrastructure from point of
  treatment to point of use

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New Deficiency 4 Distribution System

• CWS
• Pipes and storage infrastructure of water
  utility from point of treatment to water meter or
  property line

• NCWS PWS
• Pipes and storage infrastructure from point of
  treatment to point of entry into building or house

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New Deficiency 6 Plumbing

• CWS
• Pipes and storage infrastructure after point of
  entry into building or house
• Service line leading to building or house from
  water meter or property line

• NCWS PWS
• Pipes and storage infrastructure after point of
  entry into building or house

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Deficiency by Water System Type
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Jurisdiction
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Jurisdiction
27
Jurisdiction
28
Jurisdiction
29
Waterborne Disease and Outbreak Surveillance
System
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Drinking Water WBDOs in CWS by Deficiency
20032004
All Deficiencies (n16)
No Water Utility Jurisdiction or at Point of Use
(NWU/POU) 75 (12)
Source Water, Treatment Facility, or
Distribution System (SWTD) 25 (4)
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Drinking Water WBDOs in CWS by Deficiency
20032004
All Deficiencies (n16)
No Water Utility Jurisdiction or at Point of Use
(NWU/POU) 75 (12)
Source Water, Treatment Facility, or
Distribution System (SWTD) 25 (4)
Equipment distributing water (e.g., drink-mix
machine) 25
Legionella spp. in drinking water system 67
Contamination at point of use 8
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Drinking Water WBDOs in CWS by Deficiency
20032004
All Deficiencies (n16)
No Water Utility Jurisdiction or at Point of Use
(NWU/POU) 75 (12)
Source Water, Treatment Facility, or
Distribution System (SWTD) 25 (4)
Equipment distributing water (e.g., drink-mix
machine) 25
Distribution system 50
Treatment deficiency 50
Contamination at point of use 8
Legionella spp. in drinking water system 67
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Drinking Water WBDOs in NCWS by Deficiency
20032004
All Deficiencies (n10)
Inside Buildings/Houses or at Point of Use 10
(1)
Unknown 20 (2)
Source Water, Treatment Facility, or
Distribution System 70 (7)
8 WBDOs but 10 deficiencies.
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Drinking Water WBDOs in NCWS by Deficiency
20032004
All Deficiencies (n10)
Unknown 20 (2)
Inside Buildings/Houses or at Point of Use 10
(1)
Source Water, Treatment Facility, or
Distribution System 70 (7)
Plumbing system 100
8 WBDOs but 10 deficiencies.
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Drinking Water WBDOs in NCWS by Deficiency
20032004
All Deficiencies (n10)
Unknown 20 (2)
Inside Buildings/Houses or at Point of Use 10
(1)
Source Water, Treatment Facility, or
Distribution System 70 (7)
Plumbing system 100
Untreated ground water 29
Distribution system 43
Treatment deficiency 29
8 WBDOs but 10 deficiencies.
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TCR / Distribution System Questions

• Causes of distribution system deficiencies

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Waterborne Outbreaks Caused by Distribution
System Deficiencies,1971-2004
DRAFT - Preliminary Data
Office of Research and Development
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Waterborne Outbreaks Caused by Distribution
System Deficiencies,1971-2004
DRAFT - Preliminary Data
Office of Research and Development
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TCR / Distribution System Questions

• Distribution system deficiencies by etiologic
  agent

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Etiology of Waterborne Outbreaks Caused by
Distribution System Deficiencies, 1971-2004
DRAFT - Preliminary Data
Office of Research and Development
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Chemical Etiology of Waterborne Outbreaks Caused
by Distribution System Deficiencies, 1971-2004
DRAFT - Preliminary Data
Office of Research and Development
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Drinking Water Outbreaks With Deficiency 4 by
Etiologic Agent, United States 19782002 (N91)
Pathogen
Chemical
DRAFT - Preliminary Data
Unknown
Excludes outbreaks of Legionnaires Disease
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Limitations of Waterborne Disease and Outbreak
Surveillance Data

• Inconsistent environmental health data
• Lack of sensitivity
• Passive surveillance
• Not all WBDOs recognized, investigated, reported
• No reliable estimates of the number of
  unrecognized WBDOs and associated cases of
  illness are available

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Health Data and TCR
DRAFT - Preliminary Data
Excludes outbreaks of Legionnaires Disease
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TCR

• Is there an association between indicators and
  health?
• What is the strength of that association?
• Can indicators be used to identify at-risk
  systems or situations?
• Can preventive measures be applied in these
  systems or situations to prevent exposure/disease?

Health Effect
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• The findings and conclusions in this
  presentation have not been formally disseminated
  by CDC and should not be construed to represent
  any agency determination or policy