Management of a Cryptosporidiosis Outbreak in the South East

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Management of a Cryptosporidiosis Outbreak in the
South East Lessons Learned

• Dr BethAnn Roch
• Dr Ann Marie OByrne
• Consultants in Public Health Medicine, HSE-SE
• On behalf of the Incident Response Team

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Outline of Presentation

• Description of outbreak
• Results
• Action taken
• Discussion
• Issues arising
• Lessons learned

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Problem Identification

• Trigger 4 cases of cryptosporidiosis in a 3 week
  period in Carlow
• Notifiable disease in ROI since Jan 2004
• Immediate actions
• Enhanced surveillance
• Contact PEHO ? County Council
• Contact GPs ? advise vulnerable i.c. to boil
  water
• ? AIG to send stool samples
• Meeting convened between HSE-SE and County
  Council

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Epidemic Curve
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Descriptive Epidemiology

• 31 laboratory confirmed cryptosporidiosis
• 18 females, 13 males 8 cases hospitalised

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Geographical Distribution of Cases
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Enhanced Surveillance

• Other risk factors
• crèche contacts (8)
• swimming pool (5)
• private wells (9)
• animals (14)
• travel (3)
• 11 had no RF other than town water

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Results

• Water results
• Cryptosporidium 0.04/10L
• Giardia 0.02/10L
• Microbiology clear
• Faecal results
• 31 laboratory confirmed cases
• 7 samples sent for genotyping C. hominis

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Actions

• Regular meetings of IRT
• Swimming pool sampling and advice
• Private wells sampled
• Crèche visits and advice
• Council water measures
• Water sampling
• Risk assessments
• Boil notice
• Programme of works to minimise risk

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Issues arising

• Water
• Advice to vulnerable populations
• Communication

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Cryptosporidium species

• Faecal
• C. hominis
• Water
• C. parvum
• C. andersoni
• C. muris
• Implications reassurance?
• Intermittent excretion, small dose infective dose
• Immunocompromised
• Evidence of breakthrough

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An acceptable level

• Sampling
• Volume 500-1000L
• Grab/continuous
• 2 filters/3 labs
• Standards
• UK
• NI and Scotland
• Types identified
• Virulence of C hominis
• Nature of source
• Decision 0.05 oocysts/10L

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Cryptosporidium
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Clostridium perfringens

Source Carlow County Council
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C. perfringens and Cryptosporidium
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Turbidity
In line turbidity of filter outlet
Grab sample of final water turbidity
Standard 1 NTU

Source Carlow County Council
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Rainfall levels onset of illness
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Advice to vulnerable populations

• Infants
• Widespread availability/use of bottled water
• FSAI recommendations
• Immunocompromised
• Advised through medical professionals
• Recommendations
• UK and USA
• Proposed Irish guidelines
• Recommendations of IRT

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Communication

• Proactive
• Council meetings
• Press interviews
• Notice distribution and updates
• Helpline
• Website
• FAQs
• Links
• Website www.carlow.ie

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Communication - interagency

• Health Service and County Council
• IRT engineers, EHOs, public health doctors,
  surveillance scientists, microbiologist
• Protocol for microbiological incidents
• Water Liaison group meetings
• Reports written in collaboration
• Presentations supported
• Regular meetings
• Update protocol

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Lessons learned

• Interpretation of water results
• Advice to vulnerable groups
• Importance of communication
• Building good working relationships
• Management of water incidents is complex and
  requires input from several different disciplines.

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Acknowledgements

• HSE-SE staff Carlow County Council
• Dr Phil Jennings, A/DPH, HSE-M
• Dr Derval Igoe/Dr Paul McKeown, HPSC
• Dr Maire OConnor, Consultant in PHM, HSE-E
• Dr Gordon Nichols, Deputy Head, Environmental
  Enteric Diseases Dept, HPA
• Dr David Stewart, DPH, EHSSB
• Ms Gemma Leane, HSE-SE