Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water — United States, 2013–2014
Weekly / November 10, 2017 / 66(44);1216–1221
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Katharine M. Benedict, DVM, PhD1,2; Hannah Reses, MPH2; Marissa Vigar, MPH2; David M. Roth, MSPH2; Virginia A. Roberts, MSPH2; Mia Mattioli, PhD2; Laura A. Cooley, MD3; Elizabeth D. Hilborn, DVM4; Timothy J. Wade, PhD4; Kathleen E. Fullerton, MPH2; Jonathan S. Yoder, MPH, MSW2; Vincent R. Hill, PhD2 (View author affiliations)View suggested citation
What is already known about this topic?
Waterborne disease and outbreaks associated with drinking water continue to occur in the United States. CDC collects data on waterborne disease outbreaks submitted from all states and territories through the National Outbreak Reporting System.
What is added by this report?
During 2013–2014, a total of 42 drinking water–associated outbreaks were reported to CDC, resulting in at least 1,006 cases of illness, 124 hospitalizations, and 13 deaths. Legionella was responsible for 57% of outbreaks and 13% of illnesses, and chemicals/toxins and parasites together accounted for 29% of outbreaks and 79% of illnesses. Eight outbreaks caused by parasites resulted in 289 (29%) cases, among which 279 (97%) were caused by Cryptosporidium and 10 (3%) were caused by Giardia duodenalis. Chemicals or toxins were implicated in four outbreaks involving 499 cases, with 13 hospitalizations, including the first outbreaks associated with algal toxins.
What are the implications for public health practice?
Continued public health surveillance is necessary to detect waterborne disease and monitor health trends associated with drinking water exposure. When drinking water is contaminated by infectious pathogens, chemicals, or toxins, public health agencies need to provide rapid detection, identification of the cause, and response to prevent and control waterborne illness and outbreaks. Effective water management programs in buildings at increased risk for Legionella growth and transmission can reduce the risk for disease from drinking water pathogens.
Provision of safe water in the United States is vital to protecting public health (1). Public health agencies in the U.S. states and territories* report information on waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS) (https://www.cdc.gov/healthywater/surveillance/index.html). During 2013–2014, 42 drinking water–associated† outbreaks were reported, accounting for at least 1,006 cases of illness, 124 hospitalizations, and 13 deaths. Legionella was associated with 57% of these outbreaks and all of the deaths. Sixty-nine percent of the reported illnesses occurred in four outbreaks in which the etiology was determined to be either a chemical or toxin or the parasite Cryptosporidium. Drinking water contamination events can cause disruptions in water service, large impacts on public health, and persistent community concern about drinking water quality. Effective water treatment and regulations can protect public drinking water supplies in the United States, and rapid detection, identification of the cause, and response to illness reports can reduce the transmission of infectious pathogens and harmful chemicals and toxins.
To provide information about drinking water–associated waterborne disease outbreaks in the United States in which the first illness occurred in 2013 or 2014 (https://www.cdc.gov/healthywater/surveillance/drinking-surveillance-reports.html), CDC analyzed outbreaks reported to the CDC Waterborne Disease and Outbreak Surveillance System through NORS (https://www.cdc.gov/nors/about.html) as of December 31, 2015. For an event to be defined as a waterborne disease outbreak, two or more cases must be linked epidemiologically by time, location of water exposure, and illness characteristics; and the epidemiologic evidence must implicate water exposure as the probable source of illness. Data requested for each outbreak include 1) the number of cases, hospitalizations, and deaths; 2) the etiologic agent (confirmed or suspected); 3) the implicated water system; 4) the setting of exposure; and 5) relevant epidemiologic and environmental data needed to understand the outbreak occurrences and for determining the deficiency classification.§ One previously unreported outbreak with onset date of first illness in 2012 is presented but is not included in the analysis of outbreaks that occurred during 2013–2014.
Public health officials from 19 states reported 42 outbreaks associated with drinking water during the surveillance period (Table 1) (https://www.cdc.gov/healthywater/surveillance/drinking-water-tables-figures.html). These outbreaks resulted in at least 1,006 cases of illness, 124 hospitalizations (12% of cases), and 13 deaths. At least one etiologic agent was identified in 41 (98%) outbreaks. Counts of etiologic agents in this report include both confirmed and suspected etiologies, which differs from previous surveillance reports. Legionella was implicated in 24 (57%) outbreaks, 130 (13%) cases, 109 (88%) hospitalizations, and all 13 deaths (Table 1). Eight outbreaks caused by two parasites resulted in 289 (29%) cases, among which 279 (97%) were caused by Cryptosporidium, and 10 (3%) were caused by Giardia duodenalis. Chemicals or toxins were implicated in four outbreaks involving 499 cases, with 13 hospitalizations, including the first reported outbreaks (two outbreaks) associated with algal toxins in drinking water.
The most commonly reported outbreak etiology was Legionella (57%), making acute respiratory illness the most common predominant illness type reported in outbreaks (Table 2). Thirty-five (83%) outbreaks were associated with public (i.e., regulated), community or noncommunity water systems,¶ and three (7%) were associated with unregulated, individual systems. Fourteen outbreaks occurred in drinking water systems with groundwater sources and an additional 14 occurred in drinking water systems with surface water sources. The most commonly cited deficiency, which led to 24** (57%) of the 42 drinking water–associated outbreaks, was the presence of Legionella in drinking water systems. In addition, 143 (14%) cases were associated with seven (17%) outbreak reports that had a deficiency classification indicating “unknown or insufficient information.”
Among 1,006 cases attributed to drinking water–associated outbreaks, 50% of the reported cases were associated with chemical or toxin exposure, 29% were caused by parasitic infection (either Cryptosporidium or Giardia), and 13% were caused by Legionella infection (Table 2). Seventy-five percent of cases were linked to community water systems. Outbreaks in water systems supplied solely by surface water accounted for most cases (79%). Of the 1,006 cases, 86% originated from outbreaks in which the predominant illness was acute gastrointestinal illness. Three (7%) outbreaks in which treatment was not expected to remove the contaminant were associated with a chemical or toxin and resulted in 48% of all outbreak-associated cases.
Water treatment processes, regulations, and rapid response to illness outbreaks continue to reduce the transmission of pathogens, reduce exposure to chemicals and toxins, and protect the public drinking water supplies in the United States. Outbreaks reported during this surveillance period include the first reports of drinking water–associated outbreaks caused by harmful algal blooms as well as the continued challenges of preventing and controlling illnesses and outbreaks caused by Legionella and Cryptosporidium. Outbreaks in community water systems caused by chemical spills (West Virginia) (2), harmful algal blooms (Ohio), Cryptosporidium (Oregon) (3), and Legionella (Michigan) demonstrated that diverse contaminants can cause interruptions in water service, illnesses, and persistent community concern about drinking water quality. Outbreaks in community water systems can trigger large and complex public health responses because of their potential for causing communitywide illness and decreasing the availability of safe water for community members, businesses, and critical services (e.g., hospitals). These outbreaks highlight the importance of public health and water utility preparedness for emergencies related to contamination from pathogens, chemicals, and toxins.
Legionella continues to be the most frequently reported etiology among drinking water–associated outbreaks (4). All of the outbreak-associated deaths reported during this surveillance period as well as all of the outbreaks reported in hospital/health care settings or long-term care facilities, were caused by Legionella. A review of 27 Legionnaires’ disease outbreak investigations in which CDC participated during 2000–2014 identified at least one water system maintenance deficiency in all 23 investigations for which this information was available, indicating that effective water management programs in buildings at increased risk for Legionella growth and transmission (e.g., those with more than 10 stories or that house susceptible populations) can reduce the risk for Legionnaires’ disease (5,6). Although Legionella was detected in drinking water, multiple routes of transmission beyond ingestion of contaminated water more likely contributed to these outbreaks, such as aerosolization from domestic or environmental sources. Cryptosporidium was the second most common cause of both outbreaks and illnesses, demonstrating the continued threat from this chlorine-tolerant pathogen when drinking water supplies are contaminated. Existing drinking water regulations and filtration systems targeted to control Cryptosporidium help protect public health in community water systems that are primarily served by surface water sources or groundwater sources under the influence of surface water (7). Through the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Cooperative Agreement, CDC has recently begun a laboratory-based cryptosporidiosis surveillance system in the United States, CryptoNet, to better track Cryptosporidium transmission and rapidly identify outbreak sources through molecular typing (8). The cyanobacterial toxin microcystin caused the largest reported toxin contamination of community drinking water in August 2013 and September 2014 and was responsible for extensive community and water disruptions. In June 2015, the Environmental Protection Agency released specific health advisory guidance for microcystin concentrations in drinking water (9). The contamination of a community drinking water supply with 4-metholcyclohexanementanol (MCHM) also illustrates the importance of source water protection from chemicals and toxins (2).
The findings in this report are subject to at least three limitations. First, 17% of drinking water–associated outbreak reports could not be assigned a specific deficiency classification other than “unknown or insufficient information,” because of a lack of information. Furthermore, the deficiency classification most frequently reported (“presence of Legionella in drinking water systems”) does not provide insight into the specific factors contributing to Legionella amplification and transmission. Second, the detection and investigation of outbreaks might be incomplete. Because of universal exposure to water, linking illness to drinking water is inherently difficult through traditional outbreak investigation methods (e.g., case-control and cohort studies) (10). Finally, reporting capabilities and requirements vary among states and localities. Therefore, outbreak surveillance data likely underestimate actual occurrence of outbreaks and should not be used to estimate the actual number of outbreaks or cases of waterborne disease.
Public health surveillance is necessary to detect waterborne disease and outbreaks, and to continue to monitor health trends associated with drinking water exposure. Despite resource constraints, 19 states reported drinking water–associated outbreaks for 2013–2014 compared with 14 for the previous reporting period (4). In this reporting cycle, more reported outbreaks and cases were caused by parasites and chemicals than by non-Legionella bacteria, and more cases were reported from community systems than from individual systems. Most of the outbreaks and illnesses reported in this period were in community systems, which serve larger numbers of persons; outbreaks in these systems can sicken entire communities. Although individual, private water systems likely serve fewer persons than community systems, they can still result in relatively large numbers of illnesses. One outbreak reported during 2013–2014 in an individual system led to 100 estimated illnesses associated with a wedding. The public health challenges highlighted here underscore the need for rapid detection, identification of the cause, and response when drinking water is contaminated by infectious pathogens, chemicals, or toxins to prevent and control waterborne illness and outbreaks.
State, territory, and local waterborne disease coordinators, epidemiologists, and environmental health personnel; Bryanna Cikesh, Allison Miller, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Jessica Smith, Sooji Lee, Albert Barskey, Chris Edens, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC
Conflict of Interest
No conflicts of interest were reported.
Corresponding author: Katharine Benedict, firstname.lastname@example.org, 404-718-4388.
1Epidemic Intelligence Service, CDC; 2Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 3Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC; 4U.S. Environmental Protection Agency.
* Outbreak reports can be submitted by public health agencies in the U.S states, District of Columbia, Guam, Puerto Rico, Marshall Islands, Federated States of Micronesia, Northern Mariana Islands, Palau, and U.S. Virgin Islands.
† Drinking water, also called potable water, is water for human consumption (e.g., drinking, bathing, showering, hand-washing, teeth brushing, food preparation, dishwashing, and maintaining oral hygiene) and includes water collected, treated, stored, or distributed in public and individual water systems, as well as bottled water.
§ Waterborne disease outbreaks are assigned one or more deficiency classifications based on available data. The deficiencies provide information regarding how the water became contaminated, characteristics of the water system, and factors leading to waterborne disease outbreaks. Outbreaks are assigned one or more deficiency classifications based on available data. https://www.cdc.gov/healthywater/surveillance/deficiency-classification.html.
¶ Community and noncommunity water systems are public water systems that have ≥15 service connections or serve an average of ≥25 residents for ≥60 days per year. A community water system serves year-round residents of a community, subdivision, or mobile home park. A noncommunity water system serves an institution, industry, camp, park, hotel, or business and can be nontransient or transient. Nontransient systems serve ≥25 of the same persons for ≥6 months of the year but not year-round (e.g., factories and schools) whereas transient systems provide water to places in which persons do not remain for long periods of time (e.g., restaurants, highway rest stations, and parks). Individual water systems are small systems not owned or operated by a water utility that have <15 connections or serve <25 persons.
** One of the 24 outbreaks included both deficiencies 5a and 7 under the “multiple” classification.
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TABLE 1. Waterborne disease outbreaks associated with drinking water (N = 42), by state/jurisdiction and month of first case onset — Waterborne Disease and Outbreak Surveillance System, United States, 2013–2014
|State/ Jurisdiction||Month||Year||Etiology*||Predominant illness†||No. of cases||No. of hospitalizations§||No. of deaths¶||Type of water system**||Water source||Setting|
|Arizona||Jan||2014||Norovirus (S)||AGI||4||0||0||Transient, noncommunity||Unknown||Camp/Cabin Setting|
|Florida||Sep||2013||L. pneumophila serogroup 1||ARI||4||4||0||Community||Well||Hospital/Health care|
|Florida||Nov||2013||L. pneumophila serogroup 1||ARI||4||4||0||Community||Other||Other§§|
|Florida||Apr||2014||L. pneumophila serogroup 1||ARI||2||2||0||Community||Well||Hotel/Motel/Lodge/Inn|
|Florida||Jun||2014||L. pneumophila serogroup 1||ARI||3||2||0||Community||Unknown||Long-term care facility|
|Florida||Aug||2014||L. pneumophila serogroup 1||ARI||6||4||0||Community||Unknown||Hotel/Motel/Lodge/Inn|
|Indiana||Jul||2013||Cryptosporidium sp.||AGI||7||0||0||Community||Unknown||Mobile home park|
|Kansas||June||2014||L. pneumophila serogroup 1||ARI||2||2||0||Community||Unknown||Hospital/Health care|
|Maryland||Nov||2012||L. pneumophila serogroup 1||ARI||2¶¶||2¶¶||0||Community||Well||Hotel/Motel/Lodge/Inn|
|Maryland||Feb||2013||Nitrite***||AGI, Neuro||14||0||Community||Lake/Reservoir/ Impoundment||Indoor workplace/Office|
|Maryland||Apr||2014||L. pneumophila serogroup 1||ARI||2||2||0||Community||Lake/Reservoir/ Impoundment||Apartment/Condo|
|Maryland||Jul||2014||L. pneumophila serogroup 1||ARI||2||1||0||Community||Well||Hotel/Motel/Lodge/Inn|
|Maryland||Aug||2014||L. pneumophila serogroup 1||ARI||2||2||0||Community||River/Stream||Prison/Jail (Juvenile/Adult)|
|Michigan||Jun||2014||L. pneumophila serogroup 1||ARI||45||45||7||Community||River/Stream||Hospital/Health care, Community/Municipality†††|
|New York||Jul||2013||L. pneumophila serogroup 1||ARI||2||2||0||Community||Lake/Reservoir/ Impoundment||Hospital/Health care|
|New York||Jun||2014||L. pneumophila serogroup 1||ARI||2||2||0||Community||Well||Hospital/Health care|
|North Carolina||Dec||2013||L. pneumophila serogroup 1||ARI||3||2||0||Community||Unknown||Long-term care facility|
|North Carolina||Dec||2013||L. pneumophila serogroup 1||ARI||7||3||0||Community||Unknown||Long-term care facility|
|North Carolina||May||2014||L. pneumophila serogroup 1||ARI||7||6||1||Community||Other||Long-term care facility|
|North Carolina||Jun||2014||L. pneumophila serogroup 1||ARI||3||3||0||Community||Unknown||Long-term care facility|
|North Carolina||Jul||2014||L. pneumophila serogroup 1||ARI||3||2||1||Community||Unreported||Long-term care facility|
|Ohio||Apr||2013||L. pneumophila||ARI||2||2||1||Unknown||Unknown||Long-term care facility|
|Ohio§§§||Sep||2013||Cyanobacterial toxin¶¶¶||AGI||6||0||0||Community||Lake/Reservoir/ Impoundment||Community/Municipality|
|Ohio||Jul||2014||L. pneumophila serogroup 1||ARI||14||4||0||Community||River/Stream||Long-term care facility|
|Ohio||Aug||2014||Cyanobacterial toxin¶¶¶||AGI||110||Community||Lake/Reservoir/ Impoundment||Community/Municipality|
|Ohio||Oct||2014||Cryptosporidium sp. (S)****||AGI||100||0||0||Individual||River/Stream||Farm/Agricultural setting|
|Ohio||Dec||2014||Viral, unknown (S)||AGI||2||0||0||Commercially bottled||Unknown||Private residence|
|Oregon||Jun||2013||Cryptosporidium parvum IIaA15G2R1||AGI||119||2||0||Community||Lake/Reservoir/ Impoundment||Community/Municipality|
|Oregon||Sep||2014||L. pneumophila serogroup 1||ARI||4||4||1||Community||Well||Apartment/Condo|
|Pennsylvania||Dec||2013||L. pneumophila serogroup 1||ARI||2||2||0||Unknown||Unknown||Hospital/Health care|
|Pennsylvania||Feb||2014||L. pneumophila serogroup 1||ARI||5||5||0||Community||River/Stream||Long-term care facility|
|Pennsylvania||Oct||2014||L. pneumophila||ARI||2||2||1||Community||Unknown||Long-term care facility|
|Rhode Island||Apr||2013||L. pneumophila serogroup 1||ARI||2||2||1||Community||Lake/Reservoir/ Impoundment||Hospital/Health care|
|Tennessee||Jul||2013||Cryptosporidium parvum||AGI||34||0||0||Transient, noncommunity††††||Spring||Camp/Cabin setting|
|Tennessee||Jun||2014||Clostridium difficile (S); Escherichia coli, Enteropathogenic (S)||AGI||12||0||0||Nontransient, noncommunity||Well||Camp/Cabin setting; Community/Municipality|
|Virginia||Jun||2013||Cryptosporidium sp.||AGI||19||0||0||Individual||Well||Farm/Agricultural setting|
|Wisconsin||Aug||2014||Giardia duodenalis||AGI||3||0||0||Nontransient, noncommunity||Other||National forest|
|Wisconsin||Sep||2014||Campylobacter jejuni||AGI||5||0||0||Individual||Well||Private residence|
TABLE 2. Rank order (most common to least common) of etiology, water system, water source, predominant illness, and deficiencies associated with 42 drinking water outbreaks and 1,006 outbreak-related cases of illness — United States, 2013–2014
|Characteristic/Rank||Outbreaks (N = 42)||Cases (N = 1,006)|
|Category||No. (%)||Category||No. (%)|
|1||Bacteria, Legionella||24 (57.1)||Chemical/Toxin||499 (49.6)|
|2||Parasites||8 (19.1)||Parasites||289 (28.7)|
|3||Chemical/Toxin||4 (9.5)||Bacteria, Legionella||130 (12.9)|
|4||Viruses||3 (7.1)||Viruses||68 (6.8)|
|5||Bacteria, non-Legionella||1 (2.4)||Multiple bacteria||12 (1.2)|
|6||Multiple bacteria||1 (2.4)||Bacteria, non-Legionella||5 (0.5)|
|7||Unknown||1 (2.4)||Unknown||3 (0.3)|
|1||Community||30 (71.4)||Community||759 (75.4)|
|2||Noncommunity||5 (11.9)||Individual||124 (12.3)|
|3||Individual||3 (7.1)||Noncommunity||115 (11.4)|
|4||Unknown||3 (7.1)||Unknown||6 (0.6)|
|5||Bottled||1 (2.4)||Bottled||2 (0.2)|
|1||Ground water||14 (33.3)||Surface water||795 (79.0)|
|2||Surface water||14 (33.3)||Ground water||157 (15.6)|
|3||Unknown||12 (28.6)||Unknown||39 (3.9)|
|4||Mixed†||1 (2.4)||Mixed||12 (1.2)|
|5||Unreported||1 (2.4)||Unreported||3 (0.3)|
|1||ARI||24 (57.1)||AGI||862 (85.7)|
|2||AGI||17 (40.5)||ARI||130 (12.9)|
|3||AGI; Neuro||1 (2.4)||AGI; Neuro||14 (1.4)|
|1||Legionella spp. in drinking water system**||23 (54.8)||Treatment not expected to remove contaminant||485 (48.2)|
|2||Unknown/Insufficient information††||7 (16.7)||Unknown/Insufficient information||143 (14.2)|
|3||Multiple§§||3 (7.1)||Legionella spp. in drinking water system||126 (12.5)|
|4||Treatment not expected to remove contaminant¶¶||3 (7.1)||Treatment deficiency||119 (11.8)|
|5||Untreated ground water***||3 (7.1)||Untreated ground water||70 (7.0)|
|6||Distribution system†††||1 (2.4)||Multiple||42 (4.2)|
|7||Premises plumbing system§§§||1 (2.4)||Premise plumbing system||14 (1.4)|
|8||Treatment deficiency¶¶¶||1 (2.4)||Distribution system||7 (0.7)|
Suggested citation for this article: Benedict KM, Reses H, Vigar M, et al. Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water — United States, 2013–2014. MMWR Morb Mortal Wkly Rep 2017;66:1216–1221. DOI: http://dx.doi.org/10.15585/mmwr.mm6644a3.
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