Management of a Cryptosporidiosis Outbreak in the South East – Lessons Learned
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Transcript of Management of a Cryptosporidiosis Outbreak in the South East – Lessons Learned
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Management of a Cryptosporidiosis Outbreak in the South East –
Lessons Learned
Dr BethAnn Roch
Dr Ann Marie O’Byrne
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
Epi Curve for all cases
543
Cases 21
24-Jan
31-Jan
7-Feb
14-Feb
21-Feb
28-Feb
7-Mar
14-Mar
21-Mar
28-Mar
4-Apr
11-Apr
18-Apr
25-Apr
2-May
9-May
Onset (Week Commencing)
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Descriptive Epidemiology• 31 laboratory confirmed cryptosporidiosis
• 18 females, 13 males: 8 cases hospitalised
Age Distribution of Cases
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3 2
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0-5 6-20 21-40 41+Age Groups
Nu
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ases
Female
Male
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Geographical Distribution of
Cases
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• Other risk factors– crèche contacts (8)– swimming pool (5)– private wells (9)– animals (14)– travel (3)
• 11 had no RF other than town water
Enhanced Surveillance
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• 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
Results
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• 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
Actions
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Notification of cases, onset of illness and actions taken
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Date of Onset Date of Notification
Boil water advice period 14/04/05 - 24/05/05
Sion Cross output reduced22/3/05 - 26/03/05
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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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0.0
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LBoil water advice period
14/04/05 - 24/05/05
Cryptosporidium
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16 Source: Carlow County Council
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20-Sep-04 9-Nov-04 29-Dec-04 17-Feb-05 8-Apr-05 28-May-05 17-J ul-05
Clostridium Perfringens No./100ml
Clostridium perfringens
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C. perfringens and Cryptosporidium
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No. of oocysts /10L
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0.00.10.20.30.40.50.60.70.80.91.01.1
Tur
bidi
ty (N
TU
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In line turbidity of filter outletGrab sample of final water turbidity
Standard 1 NTU
Turbidity
Source: Carlow County Council
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Date of Onset
Rainfall
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 O’Connor, 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