Preparation for a Waterborne Disease Outbreak Investigation

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1. Organization

damaged pipe spilling large amount of water
  • Develop general outbreak plans, procedures, and templates prior to an outbreak.
  • List available resources and asset types, including people (e.g., environmental health, engineers, laboratorians, nurses, epidemiologists, public information officers), laboratory equipment and supplies, and response equipment. If your health department does not have the resources to adequately respond to large or complex waterborne disease outbreaks, plan for requesting needed resources from other local, state, or federal partners.
  • Consult with your departmental legal team to ensure compliance with applicable legal requirements.

2. Partners

Building relationships prior to an outbreak can strengthen partnerships during interagency responses. Individuals, agency participation, and responsibilities will vary based on the cause of the outbreak. Organizations and agencies that could provide assistance during outbreaks include:

  • Other local or state health departments
  • Other local or state agencies with jurisdiction involving water (e.g., departments of environmental quality/protection)
  • Healthcare facilities
  • Clinical and environmental laboratories
  • Municipal water systems and recreational water facilities
  • Local media
  • Emergency management agencies
  • Child care centers and elder care facilities
  • Community based organizations which could provide support to vulnerable populations (e.g., persons experiencing homelessness, HIV positive individuals)

During an outbreak, it can be important to identify and work with state and federal regulatory agencies and public health legal authorities.

Establish operational memorandums of understanding or interagency agreements, as appropriate.

Example of Key Partners: Colorado Statewide cryptosporidiosis outbreak, 2007

On August 20, 2007, the Colorado Department of Public Health and Environment (CDPHE) identified an increase in the number of reported cases of cryptosporidiosis.  Cryptosporidium species are chlorine-resistant, protozoan parasites that causes prolonged watery diarrhea.  By August 31, 2007, CDPHE had received 56 reports of cryptosporidiosis for the month of August.  The expected number of reported cases of cryptosporidiosis in Colorado for August is 12.

Key Partners of the Colorado Department of Public Health and Environment (CDPHE)

  • 7 + County Health Departments
  • Colorado State Laboratory
  • Division of Parasitic Diseases, CDC

The CDPHE worked with local county health departments, state laboratory, CDC laboratory, and CDC partners to develop and administer a laboratory survey, stool specimen investigation, and a case-control study to determine sources of the outbreak and develop recommendations for outbreak control.

3. Training and Resources

Several trainings and resources are available to prepare for waterborne disease outbreak investigations. These trainings provide knowledge on water sources and outbreak investigation methods.

4. Communication

Internal Communication
  • Identify all key partners within your organization and designate a shared space to store outbreak materials, develop a communication distribution list, and establish the most efficient ways to communicate outbreak updates. Depending on the magnitude of the outbreak and the degree of involvement with other agencies, the department may decide to follow the Incident Command System (ICS) to assist in command, control, and coordination of the emergency response.
Communications with Partners
  • Regular communication with key partners through pre-established channels (i.e. conference call, email, etc.) is essential to keep partners informed, plan next steps, and share information on the status of the outbreak.
  • Decide on a mechanism for sharing information, such as e-mail, state communication systems, or national communication systems, such as EPI-X.
  • Plan for daily situational reports (SitReps). These regular summaries should be updated with important case information, including clinical information, non-identifying demographic information (sex, age), and updates and progress on the investigation. SitReps should not include protected health information (PHI), such as patient names, patient addresses, medical record numbers, or dates of birth.
Public Communication

Providing information regularly to help people make the best possible decisions for their health and well-being during waterborne disease outbreaks is a crucial outbreak response activity. Emergency risk communication must be done in rapid timeframes and without knowing everything about the outbreak. Because water systems are essential to multiple community systems, it is important for the public to understand the potential risk to their health and what actions they can take to reduce their risk. Even if the health department is not responsible for regulating the water system, the public will look to the health department for credible health information and updates on water safety.

Planning ahead for outbreak communication can help disseminate timely, consistent, and reliable information to the public. While it is impossible to predict the type of contamination or illness prior to an outbreak, it may be possible to plan for the types of questions that will be asked and how they can be addressed in ways that control the outbreak and provide guidance for people to protect their health.

The following communication guidance may be helpful for communication planning:

Communication Plan

Creating a Communication Plan will allow you to deliver consistent and effective messaging to the right audience at the right time.

To develop an effective communication plan, answer these questions within the strategy:

  • Goal—What do you want people to know or do?
  • Audience(s)—Who are you communicating with?
  • Message—What information do you want to communicate?
  • Strategies—How are you going to achieve your communication goal?
  • Timeline—When are you going to do it?
  • Staffing and/or partnerships—Who is going to do it?
  • Budget—How much will it cost?
Media Relations
  • Identify and establish a working relationship with your Public Information Officer (PIO). Plan for coordination with other response PIOs (e.g., water utility, emergency management agency).
  • Identify a primary spokesperson for media interviews. The primary spokesperson should have detailed knowledge of the situation and preferably have previous experience with media interviews. Identify a secondary spokesperson for back-up in the event the primary is not available. Share this information with your PIO.
  • Work with your PIO to develop and maintain a distribution list of local news agencies and reporters with current contact information.
    • Use this list to send news and updates about outbreaks, recent events, and other information.
  • Discuss and agree upon a schedule for sending updates to the media during an outbreak or event.
    • This should be done on a case-by-case basis; every outbreak or event will have different communication needs.
Press Releases, Social Media, and Internal Talking Points
  • Develop internal talking points with your PIO. Consider including pre-determined answers to questions that may be asked by reporters, the public, or other agencies once a press release is issued.
    • Share internal talking points with established key contacts and partners for message consistency.
  • Determine the best channels for communicating with the affected community. These could include press releases, press conferences, website updates, social media messages, or emergency alerts.
  • When appropriate, press releases should include information regarding:
    • Who is affected by the outbreak or event
    • What is the contamination (e.g., pathogen, toxin, chemical)
    • Where the outbreak or event is occurring
    • When it happened
    • What is being done to resolve the issue(s) and steps people can take to protect themselves
  • Keep press releases brief and use clear and simple language. Post on website and social media.
    • Be responsive to reporters’ questions.
      • Provide transparent answers for what information is known and unknown.
      • Share what steps are being taken to move the investigation forward to address current gaps in information.
  • Determine what the case definition is and the number of cases for release in a public case count.
    • In uncertain circumstances, it is acceptable to leave room for changing case counts, as ongoing tests are verified or case definitions change. For example, consider using language such as “greater than” or “less than (x) cases,” rather than giving exact numbers.
  • Identify a clearance chain for reviewing all public information before release.
    • Share a draft of the press release with established key contacts and partners before release.
  • Include pathogen-specific information in communication. Consider adding this information to press releases or your department website.
  • Consider communication channels to reach special populations (e.g., non-English speakers).
  • Determine how and when to inform the public that the outbreak event is over and that the health risk has subsided.
  • For drinking water outbreaks, use the tools and templates in the Drinking Water Advisory Communication Toolbox.