John Sarisky

A Waterborne Outbreak of Gastroenteritis with Multiple Etiologies among Resort Island Visitors and Residents: Ohio, 2004

BACKGROUND The implementation of treated municipal water systems in the 20th century led to a dramatic decrease in waterborne disease in the United States. However, communities with deficient water systems still experience waterborne outbreaks. In August 2004, we investigated an outbreak of gastroenteritis on South Bass Island, Ohio, an island of 900 residents that is visited by >500,000 persons each year. METHODS To identify the source of illness, we conducted a case-control study and an environmental investigation. A case was defined as diarrhea in a person who traveled to the island during the period from May 1 through 30 September 2004 and became ill within 2 weeks after the visit. Healthy travel companions served as matched control subjects. We also performed an environmental assessment and extensive testing of island water sources. RESULTS Among the 1450 persons reporting illness, Campylobacter jejuni, norovirus, Giardia intestinalis, and Salmonella enterica serotype Typhimurium were identified in 16, 9, 3, and 1 persons, respectively. We interviewed 100 case patients and 117 matched control subjects. Case patients were more likely to drink water on the island than control subjects (68% vs. 35%; matched odds ratio, 4.3; 95% confidence interval, 2.2-9.3). Sampling of ground water wells indicated contamination with multiple fecal microbes, including Escherichia coli, C. jejuni, Salmonella species, and Giardia species. Irregularities in sewage disposal practices that could have contaminated the underground aquifer were noted. CONCLUSIONS The combined epidemiological and environmental investigation indicated that sewage-contaminated ground water was the likely source of this large outbreak. Long-term changes to the islands water supply and sewage management infrastructure are needed.

A Waterborne Outbreak of Norwalk-Like Virus among Snowmobilers—Wyoming, 2001

In February 2001, episodes of acute gastroenteritis were reported to the Wyoming Department of Health from persons who had recently vacationed at a snowmobile lodge in Wyoming. A retrospective cohort study found a significant association between water consumption and illness, and testing identified Norwalk-like virus (NLV) in 8 of 13 stool samples and 1 well. Nucleotide sequences from the positive well-water specimen and 6 of the positive stool samples were identical. This multistrain NLV outbreak investigation illustrates the importance of NLV as a cause of waterborne illness and should encourage monitoring for NLVs in drinking water.

Outbreaks of Escherichia coli O157 infections at multiple county agricultural fairs: a hazard of mixing cattle, concession stands and children.

Escherichia coli O157 infections cause an estimated 60 deaths and 73 000 illnesses annually in the United States. A marked summer peak in incidence is largely unexplained. We investigated an outbreak of E. coli O157 infections at an agricultural fair in Ohio and implicated consumption of beverages made with fairground water and sold by a geographically localized group of vendors who were all on the same branch of the fairground water distribution system. To examine county fair attendance as a risk factor for infection, we conducted two further epidemiological studies. In the first, we enhanced surveillance for E. coli O157 infections in 15 Northeast Ohio counties during the 2000 agricultural fair season and showed increased risk of E. coli O157 infection among fair attendees. In the second study, we examined Ohio Public Health Laboratory Information Service (PHLIS) data for 1999 using a time-varying covariate proportional hazards model and demonstrated an association between agricultural fairs and E. coli O157 infections, by county. Agricultural fair attendance is a risk factor for E. coli O157 infection in the United States and may contribute to the summer peak in incidence. Measures are needed to reduce transmission of enteric pathogens at agricultural fairs.

Community Environmental Health Assessment in Peru's Desert Hills and Rainforest

Perus expanding population and rapid urbanization--a result of migration to its largest cities--have stressed the countrys public services infrastructure and the provision of public health and environmental health services. In response, the Ministry of Health established the General Directorate of Environmental Health (DIGESA), the branch charged with assuring adequate environmental health services to populations in rural and urban areas. The magnitude of the environmental health problems in peri-urban settlements, however, has exceeded the capacity of DIGESA to respond. The Urban Environmental Health Project is an effort to develop the ability of local communities to address these problems

A community demand-driven approach toward sustainable water and sanitation infrastructure development

In September 2001, Cooperative Assistance and Relief Everywhere, Peru Country Office (CARE Peru), obtained funding from the United States Agency for International Development (USAID) to implement community-supported, condominial water and sanitation interventions in Manuel Cardozo Dávila, a settlement in Iquitos, Peru. With technical support from the Centers for Disease Control and Prevention (CDC), CARE Perus Urban Environmental Health Models (Modelos Urbanos de Salud Ambiental [MUSA]) project built on previous work from implementing the Protocol for Assessing Community Excellence in Environmental Health in this same community. The project led to the municipal water supply distribution system being extended 1.3 kilometers into the Southern zone of Iquitos, where it connected to the condominial water system. Altogether, 1030 households were connected to the water supply system after the installation of a condominial water and sewerage system in Cardozo. Diarrheal disease decreased by 37% for children less than 5 years of age from 2003 to 2004. This paper illustrates the strategy used by CARE Peru in conjunction with the Cardozo community to assure that the local demand for improved water and sanitation was met.

Beyond compliance: environmental health problem solving, interagency collaboration, and risk assessment to prevent waterborne disease outbreaks

A systems approach to environmental health problem solving was used to investigate two waterborne norovirus outbreaks in Wyoming and can serve in the development of improved prevention strategies. An interagency collaboration to prevent waterborne disease involving local, state, and federal partners was designed to coordinate response to outbreak investigations. Improved risk assessment and reporting procedures were also integrated to ensure better availability of necessary data. Public health entities should implement sustainable intersectoral interventions to prevent waterborne disease that not only improve regulatory compliance but also have a positive impact on community health outcomes. Collaborative preventive health and water system protection activities should receive priority attention for implementation in state and local jurisdictions.

Strengthening the Capacity of Local Health Agencies Through Community-Based .Assessment and Planning

Objectives. We evaluated the effectiveness of the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) in building competency in essential environmental health services and renewing efforts to engage the community in problem solving. Competency and community engagement have been identified by environmental health practitioners as important to meet new threats to public health. Methods. We conducted a national survey and 24 case studies of public health agencies. We invited 917 organizations to participate in the national survey because they had requested a copy of the protocol. Results. We received 656 total responses: 354 had not considered implementation, 302 had considered implementation, and 66 had implemented PACE EH. For the 24 case studies, we interviewed 206 individuals in communities implementing PACE EH. We found that PACE EH has had a positive effect on building community and professional networks, enhancing leadership, developing workforce competence, and expanding definitions of environmental health practice. Conclusions. With appropriate investments, PACE EH can be an effective tool to meet the environmental health challenges identified by local environmental health practitioners and state, tribal, and federal agencies.

A Performance Management Initiative for Local Health Department Vector Control Programs

Local health department (LHD) vector control programs have experienced reductions in funding and capacity. Acknowledging this situation and its potential effect on the ability to respond to vector-borne diseases, the U.S. Centers for Disease Control and Prevention and the Public Health Foundation partnered on a performance management initiative for LHD vector control programs. The initiative involved 14 programs that conducted a performance assessment using the Environmental Public Health Performance Standards. The programs, assisted by quality improvement (QI) experts, used the assessment results to prioritize improvement areas that were addressed with QI projects intended to increase effectiveness and efficiency in the delivery of services such as responding to mosquito complaints and educating the public about vector-borne disease prevention. This article describes the initiative as a process LHD vector control programs may adapt to meet their performance management needs. This study also reviews aggregate performance assessment results and QI projects, which may reveal common aspects of LHD vector control program performance and priority improvement areas. LHD vector control programs interested in performance assessment and improvement may benefit from engaging in an approach similar to this performance management initiative.