VDH, Waterborne Hazards Control Program

Matt Skiljo Waterborne Hazards Control Program Coordinator VDH, Division of Environmental Epidemiology [email protected] 804-864-8128

Overview • Background • Recreational Water Illnesses • Waterborne Hazards Programs • Waterborne Illness Outbreak Guidelines • 2013 Suspected Waterborne Outbreaks • Environmental Monitoring – EPI Support

OEPI - Division of Environmental Epidemiology Mission: Prevent human disease due to harmful exposure to chemical and biological agents in the environment and from transmission of disease from animals.

Division Programs: • Rabies & Zoonotic Diseases • Toxic Substances • Vector-borne Diseases • Waterborne Hazards

Waterborne Hazards Control Program Mission:

Prevent and control water-related health problems in Virginia. This is accomplished by investigating reports of illnesses related to water exposure, conducting epidemiological studies to determine risk factors for waterborne illnesses, contributing to the development of water-related policies and regulations, and maintaining databases on water related illnesses and water quality.

http://www.vdh.virginia.gov/epidemiology/DEE/Waterborne/

Recreational Water Illnesses (RWIs) • Caused by swallowing, breathing in mists or aerosols of, or having contact with contaminated water in swimming pools, hot tubs, water parks, water play areas, interactive fountains, lakes, rivers, or oceans. • Most are gastrointestinal caused by ingestion of water containing bacteria, viruses, protozoa • E. coli, Norovirus, Rotavirus, Adenovirus, Crypto, Giardia, & others

• Others: Respiratory, eye/ear/skin, & neurological infections • Legionellosis, PAM, Vibrio infections, and others

• Summer months = more cases, more exposures • http://www.cdc.gov/healthywater/swimming/rwi/

RWI Prevention • Don’t swim if you are ill, or have diarrhea • Shower before and after swimming • Avoid swallowing water when swimming • Don’t swim with cuts or open wounds • Avoid swimming in areas where dead fish are present • Observe recommendations listed on posted signs • Avoid swimming for a few days after heavy rainfall • Take children on bathroom breaks or change diapers often • Hold your nose/wear nose plugs when underwater, diving, or swimming in hot, shallow freshwater bodies.

Coastal Beach Monitoring • Weekly bacteria monitoring at 46 coastal beaches • Samples are analyzed for enterococci bacteria, (FIB) • Results are compared to VA Water Quality Standards • Marine water: 104 cfu/100ml for enterococci • Based on EPA, national epidemiological studies • People are more likely to become ill when exposed to ambient waters with FIB above WQS

Coastal Beach Monitoring • Goal: Reduce RWIs by notifying the public when water quality does not meet state WQS • Swimming Advisories and Closures are issued • Notification Methods: • Signs posted at public access/swimming sites • Local press release • VDH website

• Virginia Tech – Microbial Source Tracking

Coastal Beach Monitoring • 2013 qPCR Study at Virginia Beach • Results available 2-4 hours after analysis begins • Goal: Evaluate performance and logistics of method • Conclusions: Cannot be used at this time • Inhibition - magnitude & frequency unacceptable • EPA’s recommended bacteria standard not accurate for VB waters

• @VDHBeach: Tweeting beach advisories (new for 2014) • New EPA Recreational Water Quality Criteria (bacteria)

• Updated epidemiological studies (FIB values & RWIs) • Recommended to states, but requirement for Beach Monitoring

Harmful Algal Blooms (HABs) • Algae: Naturally-occurring organisms (phytoplankton) in marine/freshwater • Bloom: when environmental conditions are favorable • HABs: Algal blooms that are harmful to humans, aquatic life, or environment • VA waters monitored when blooms, fish kills, or illnesses reported • VA waters monitored routinely at shellfish harvesting areas • Labs (ODU & VIMS) analyze water samples for algal species & toxins • Marine & freshwater HABs can cause illness in people and pets

Harmful Algal Blooms (HABs) • How can people/pets become ill from HABs • Consumption of shellfish or finfish caught from bloom water • Dermal contact with algal toxin(s) during bloom events • Inhalation of algal toxin(s) during bloom events • Ingestion of water contaminated with algal toxin(s) • VDH Public Notification • Posting signs on-site • Local Press Release • VDH Website

Harmful Algal Blooms (HABs) • CDC’s NORS: Developing HABs module • Capture reported HABs illnesses, including single cases • Capture associated algal bloom & toxin details • Spring 2014 workgroup and workshop • Stay tuned… • VDH-HABs Hotline: 804-238-6154 • Established & maintained to receive illness/bloom reports • CDC MMWR (Jan 2014): Algal Bloom-Associated Disease Outbreaks Among Users of Freshwater Lakes – U.S. 2009-2010

Fish Consumption Advisories • • • •

Recommended consumption limits of fish species PCBs, Mercury, Kepone, Dioxin, and PBDEs DEQ collects fish & analyzes concentrations VDH reviews results data, lists consumption advisories, & issues public notification • Location of Advisories: • VDH website • on-site signage • DGIF website & license book

http://www.vdh.virginia.gov/epidemiology/DEE/ PublicHealthToxicology/Advisories/index.htm

DEQ – Water Quality Assessments • DEQ collects water samples routinely for bacteria • E. coli & enterococci (FIB) • Determines if waters are “impaired” for recreational use • Impaired: Exceeds state water quality standards • Provides classification of long-term condition of waters • Increased risk of recreational water illness • Impaired waters are listed on DEQ’s website http://www.deq.virginia.gov/Programs/Water/WaterQualityInformationTMDLs/Wa terQualityAssessments/2012305(b)303(d)IntegratedReport.aspx

DEQ – Reports of Pollution Incidents • DEQ notifies VDH of pollution incidents to waters • Sewage discharges • Chemical spills

• Public health impacts: • Recreational use • Drinking Water • Shellfish/Fish Consumption

• VDH determines if discharges impact public health • Public notification issued if public health risks identified • 2013 Coal Ash & Crude Oil incidents

2012 Naegleria fowleri Study • Collaborative study with CDC and other states. • Determine environmental conditions contributing to the presence of N. fowleri. • Collected water & sediment samples at 5 VA lakes • N. fowleri – IMS & culture • Total Coliform, E. Coli, HPC • Temp, DO, Turb, TOC, Hardness, Nitrogen, Fe, Mn, P

• Results: • No relationships able to be determined • All results for N. fowleri (-), except one sample

Statewide Water Quality Issues • Assist LHDs with water quality issues • Recommendations for local water quality monitoring programs • Lake Associations • River Keepers & Environmental groups • Universities

• Suspected waterborne disease outbreaks

Waterborne Illness Outbreak Guidelines • OEPI – Disease Control Manual • Investigation components: • • • • •

ID potential disease-causing agents Determine scope/extent of the population affected or at risk Collect appropriate clinical and environmental samples Administer questionnaire to assess symptoms and exposures ID and implement all potential control measures

• Team approach to investigation, including: • • • • • •

District Health Director(s) Nursing/Epi staff Environmental Health Staff DEE-Waterborne Hazards Staff Office of Drinking Water Staff Other local members, as needed

Update planned

E. coli at a Summer Camp • • • • • • • • • •

Gastroenteritis in children attending a summer camp Attack rate: 1.25%, 5 of 400 campers (1 confirmed, 4 probable) Symptoms: Diarrhea, vomiting, abdominal cramps, bloody stools Care: 1 visited emergency room, 2 visited health care provider 3 human stool specimens collected • Shiga-toxin producing E. coli (non-O157:H7) & A. hydrophila Incubation period unknown, duration of 24-72 hours Investigation limited by poor response rate of cases (50%) Some cases reported ingesting water Site visit: District Epi, District EH, Foodborne Epi, DEE Environmental Monitoring: • E. coli bacteria – fecal indicator bacteria (very low) • Water quality parameters

E. coli at a Summer Camp

Cryptosporidiosis at a Summer Camp • • • • • • •

Gastroenteritis in children attending a youth camp Attack rate: 13%, 19 of 150 campers (4 confirmed, 15 probable). Symptoms: Diarrhea, abdominal cramps, anorexia, nausea Care: 2 visited emergency room, 8 visited health care provider Cryptosporidium parvum isolated in human stool samples Incubation period of 5 days avg, duration of 7 days avg. Possible Sources • Reported contact with nearby river water • Drinking water received from on-site private well • Poor sanitation and food handling

• Site visit: District Epi, District EH, Foodborne Epi, DEE • Environmental Monitoring: • E. coli bacteria – fecal indicator bacteria (high) • Water quality parameters

Cryptosporidiosis at a Summer Camp

DCLS – Water Analysis • Ambient Water • Lakes, rivers, streams • FIB: E. coli and enterococci

• Drinking Water Wells • Private and public wells • Total coliform bacteria and E. coli/fecal coliform

• Limited microbiology water analysis capabilities • Crypto/Giardia certification in 2015

CDC – Water Analysis • Water, Sanitation, and Hygiene (WASH) Laboratory • Environmental Micro Lab: • Samples: Water, wastewater, soil, sediment, etc. • Detect/quantify viruses, bacteria, & parasites • Molecular Epi Lab: • Clinical & Environmental sample analyses • Genotypes/subtypes protozoan parasites • Tracks sources of protozoan parasites • Free-Living Amebas Lab: • Detects FLAs in environmental samples • Diagnoses amebic infections • Develops & Assesses drug therapies

Work in Progress – Waterborne Haz Program • Continue environmental sampling consultation or assistance during suspected waterborne illness outbreaks. • Establish procedures with CDC WASH lab on logistics of environmental sampling, shipping, analyses, etc. • Applied for CDC ELC grant for Waterborne Disease Coordinator to conduct enhanced/historical surveillance and assist DEE/DSI in outbreak response and education. • Update Waterborne Illness Outbreak sections of OEPI Disease Control Manual • Improve procedures & response to pollution incidents in state waters affecting public health

Acknowledgements/Partners • VDH – LHD Staff • VDH – Division of Shellfish Sanitation • Virginia Tech • Virginia Institute of Marine Science • Old Dominion University • Dept of Environmental Quality • Dept. of Game and Inland Fisheries • Division of Consolidated Laboratory Services • Center for Disease Control and Prevention • Environmental Protection Agency

Questions?