Publications, Data, & Statistics

Data & Statistics

The figures and tables on the following pages represent information on cases of primary amebic meningoencephalitis (PAM) that occurred from 1962 – 2019.

Publications

Cope JR, Ali IK. Primary amebic meningoencephalitis: what have we learned in the last 5 years?external icon Curr Infect Dis Rep. 2016;18(10):31.
Siddiqui R, Khan NA. Primary amoebic meningoencephalitis caused by Naegleria fowleri: An old enemy presenting new challenges.external iconPLoS Negl Trop Dis. 2014;8(8):e3017.
Visvesvara GS. Free-living amebae as opportunistic agents of human disease.external icon J Neuroparasitol. 2010;1.
Visvesvara GS, Moura H, Schuster FL. Pathogenic and opportunistic free-living amoebae: Acanthamoeba spp.,Balamuthia mandrillaris, Naegleria fowleri, and Sappinia diploidea.external icon FEMS Immunol and Med Microbiol. 2007;50:1–26.
Visvesvara GS. Pathogenic and Opportunistic Amebae. Manual of Clinical Microbiology, 9th ed. Murray PR, Baron EJ, Jorgensen JH, Landry ML, Pfaller MA, editors. Washington DC: ASM Press. 2007. p. 2082-91.
Marciano-Cabral F, Cabral G. Acanthamoeba spp. as agents of disease in humans.external iconClin Microbiol Rev. 2003;16(2):273-307.

Capewell LG, Harris AM, Yoder JS, Cope JR, Eddy BA, Roy SL, Visvesvara GS, Fox LM, Beach MJ. external icon J Ped Infect Dis. 2014;4(4):e68-75.
Hlavsa MC, Roberts VA, Anderson AR, Hill VR, Kahler AM, Orr M, Garrison LE, Hicks LA, Newton A, Hilborn ED, Wade TJ, Beach MJ, Yoder JS. Surveillance for waterborne disease outbreaks and other health events associated with recreational water use — United States, 2007–2008. MMWR Surveill Summ. 2011;60:1-37.
Yoder JS, Eddy BA, Visvesvara GS, Capewell L, Beach MJ. The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008.external icon Epidemiol Infect. 2010;138(7):968-75.
Yoder J, Hlavsa M, Craun GF, Hill V, Roberts V, Yu P, Hicks LA, Alexander NT, Calderon RL, Roy SL, Beach MJ. Surveillance for waterborne disease and outbreaks associated with recreational water use and other aquatic facility-associated health events — United States, 2005–2006. pdf icon[PDF – 72 pages] MMWR Surveill Summ. 2008;57:SS-9.
Herwaldt BL, Craun GF, Stokes SL, Juranek DD. Waterborne-disease outbreaks, 1989-1990. pdf icon[PDF – 22 pages] MMWR Surveill Summ. 1991;40:1-21.

Other recreational water-related MMWR Surveillance summaries can be found on the Surveillance Summaries for Waterborne Disease and Outbreaks page.

Cope JR, Murphy J, Kahler A, Gorbett DG, Ali I, Taylor B, Corbitt L, Roy S, Lee N, Roellig D, Brewer S, Hill VR. Primary amebic meningoencephalitis associated with rafting on an artificial whitewater river: case report and environmental investigation.external icon Clin Infect Dis. 2018;66(4):548-53.
Ghanchi NK, Khan E, Khan A, Muhammad W, Malik FR, Zafar A. Naegleria fowleri meningoencephalitis associated with public water supply, Pakistan, 2014. Emerg Infect Dis. 2016;22(10):1835-7.
Booth PJ, Bodager D, Slade TA, Jett S. Notes From the Field: Primary amebic meningoencephalitis associated with hot spring exposure during international travel — Seminole County, Florida, July 2014. MMWR Morb Mortal Wkly Rep. 2015;64(43):1226.
Abrahams-Sandí E, Retana-Moreira L, Castro-Castillo A, Reyes-Batlle M, Lorenzo-Morales J. Fatal meningoencephalitis in child and isolation of Naegleria fowleri from hot springs in Costa Rica. Emerg Infect Dis. 2015;21(2)doi:10.3201/eid2102.141576.
Cope JR, Ratard RC, Hill VR, Sokol T, Causey JJ, Yoder JS, Mirani G, Mull B, Mukerjee KA, Narayanan J, Doucet M, Qvarstrom Y, Poole CN, Akingbola OA, Ritter JM, Xiong Z, da Silva A, Roellig D, Van Dyke R, Stern H, Xiao L, Beach MJ. The first association of a primary amebic meningoencephalitis death with culturable Naegleria fowleri in tap water from a U.S. treated public drinking water system.external icon Clin Infect Dis. 2015;60(8):e36-42.
CDC. Primary amebic meningoencephalitis associated with ritual nasal rinsing — St. Thomas, U.S. Virgin Islands, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(45):903.
Yoder JS, Straif-Bourgeois S, Roy SL, Moore TA, Visvesvara GS, Ratard RC, Hill V, Wilson JD, Linscott AJ, Crager R, Kozak NA, Sriram R, Narayanan J, Mull B, Kahler AM, Schneeberger C, da Silva AJ, Beach MJ. Deaths from Naegleria fowleri associated with sinus irrigation with tap water: a review of the changing epidemiology of primary amebic meningoencephalitis.external icon Clin Infect Dis. 2012;1-7.
Kemble SK, Lynfield R, DeVries AS, Drehner DM, Pomputius WF 3rd, Beach MJ, Visvesvara GS, da Silva AJ, Hill VR, Yoder JS, Xiao L, Smith KE, Danila R. Fatal Naegleria fowleri infection acquired in Minnesota: possible expanded range of a deadly thermophilic organism.external icon Clin Infect Dis. 2012;54:805-9.
Tuppeny M. Primary amoebic meningoencephalitis with subsequent organ procurement: a case study.external icon J Neurosci Nurs. 2011;43(5):274-9.
Yoder JS, Eddy BA, Visvesvara GS, Capewell L, Beach MJ. The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008.external icon Epidemiol Infect. 2010;138(7):968-75.
Puzon GJ, Lancaster JA, Wylie JT, Plumb IJ. Rapid detection of Naegleria fowleri in water distribution pipeline biofilms and drinking water samples.external icon Environ Sci Technol. 2009;43(17):6691-6.
US Census Bureau. Statistical Abstract of the United States: 2012. Arts, Recreation, and Travel: Participation in Selected Sports Activities 2009. excel icon[XLS – 1 MB]external icon 2013.
Bennett WM, Nespral JF, Rosson MW, McEvoy KM. Use of organs for transplantation from a donor with primary meningoencephalitis due to Naegleria fowleri.external icon Am J Transplant. 2008;8:1334-5.
Blair B, Sarkar P, Bright KR, Marciano-Cabral F, Gerba CP. Naegleria fowleri in well water.external icon Emerg Infect Dis. 2008;14:1499-501.
Visvesvara GS, De Jonckheere JF, Sriram R, Daft B. Isolation and molecular typing of Naegleria fowleri from the brain of a cow that died of primary amebic meningoencephalitis.external icon J Clin Microbiol. 2005;43(8):4203-4.
Maclean RC, Richardson DJ, LePardo R, Marciano-Cabral F. The identification of Naegleria fowleri from water and soil samples by nested PCR.external icon Parasitol Res 2004;93:211.
Ettinger MR, Webb SR, Harris SA, McIninch SP, C Garman G, Brown BL. Distribution of free-living amoebae in James River, Virginia, USA.external icon Parasitol Res. 2003;89(1):6-15.
Sheehan KB, Fagg JA, Ferris MJ, Henson JM. PCR detection and analysis of the free-living amoeba Naegleria in hot springs in Yellowstone and Grand Teton National Parks.external icon Appl Environ Microbiol. 2003;69(10):5914-8.
Cabanes PA, Wallet F, Pringuez E, Pernin P. Assessing the risk of primary amoebic meningoencephalitis from swimming in the presence of environmental Naegleria fowleri.external icon Appl Environ Microbiol. 2001;67(7):2927-31.
John DT, Howard MJ. Seasonal distribution of pathogenic free-living amebae in Oklahoma waters.external icon Parasitol Res 1995;81(3):193–201.
Dorsch MM, Cameron AS, Robinson BS. The epidemiology and control of primary amoebic meningoencephalitis with particular reference to South Australia.external icon Trans R Soc Trop Med Hyg. 1983;77(3):372-7
John DT, Nussbaum SL. Naegleria fowleri infection acquired by mice through swimming in amebae-contaminated water.external icon J Parasitol. 1983;69(5):871-4.
Sykora JK, Keleti G, Martinez AJ. Occurrence and pathogenicity of Naegleria fowleri in artificially heated waters.external icon Appl and Envion Microbiol. 1983;45:974-9.
Duma RJ. Study of pathogenic free-living amebas in fresh-water lakes in Virginia. EPA Publication. 1980;EPA-PB-126369, Summary, 1981 is EPA-600/S1-80-037.
Wellings FM, Amuso PT, Chang SL, Lewis AL. Isolation and identification of pathogenic Naegleria from Florida lakes.external icon Appl Environ Microbiol. 1977;34(6):661–7.
Stevens AR, Tyndall RL, Coutant CC, Willaert E. Isolation of the etiological agent of primary amoebic meningoencephalitis from artificially heated waters.external icon Appl Environ Microbiol. 1977;34(6):701-5.
Griffin JL. Temperature tolerance of pathogenic and nonpathogenic free-living amoebas.external icon Science. 1972;178(4063):869-70.
Anderson K, Jamieson A. Primary amoebic meningoencephalitis.external icon Lancet. 1972;1(7756):902–3.
dos Santos Neto G. Fatal primary amebic meningoencephalitis. A retrospective study in Richmond, Virginia.external icon Am J Clin Pathol. 2016;54(5):737-42.

Visvesvara GS. Amebic meningoencephalitides and keratitis: challenges in diagnosis and treatment.external icon Curr Opin Infect Dis. 2010 Dec;23(6):590-4.
Visvesvara GS. Parasite Culture: Acanthamoeba and Naegleria spp. In: Garcia LS, editor. Clinical Microbiology Procedures Handbook. 3rd ed. Washington, DC: ASM Press; 2010.
da Rocha-Azevedo B, Tanowitz HB, Marciano-Cabral F. Diagnosis of infections caused by pathogenic free-living amoebae.external icon Interdiscip Perspect Infect Dis. 2009;2009:251406.
Qvarnstrom Y, Visvesvara GS, Sriram R, da Silva AJ. Multiplex real-time PCR assay for simultaneous detection of Acanthamoeba spp., Balamuthia mandrillaris, and Naegleria fowleri.external icon J Clin Microbiol. 2006;44(10):3589-95.
Robinson BS, Monis PT, Dobson PJ. Rapid, sensitive, and discriminating identification of Naegleria spp. by real-time PCR and melting-curve analysis.external icon Appl Environ Microbiol. 2006;72(9):5857-63.
Marciano-Cabral F, MacLean R, Mensah A, LaPat-Polasko L. Identification of Naegleria fowleri in domestic water sources by nested PCR.external icon Appl Environ Microbiol. 2003;69(10):5864-9.
Mull BJ, Jothikumar N, Hill VR. Improved method for the detection and quantification of Naegleria fowleri in water and sediment using immunomagnetic separation and real-time PCR.external icon J Parasitol Res. 2013;doi:10.1155/2013/608367.

Cope JR, Conrad DA, Cohen N, Cotilla M, DaSilva A, Jackson J, Visvesvara GS. Use of the novel therapeutic agent miltefosine for the treatment of primary amebic meningoencephalitis: report of 1 fatal and 1 surviving case.external icon Clin Infect Dis. 2016;62(6):774-6.
Linam WM, Ahmed M, Cope JR, Chu C, Visvesvara GS, da Silva AJ, Qvarnstrom Y, Green J. Successful treatment of an adolescent with Naegleria fowleri primary amebic meningoencephalitis.external icon Pediatrics. 2015;135(3):e744-8.
Capewell LG, Harris AM, Yoder JS, Cope JR, Eddy BA, Roy SL, Visvesvara GS, Fox LM, Beach MJ. Diagnosis, clinical course, and treatment of primary amoebic meningoencephalitis in the United States, 1937–2013.external icon J Ped Infect Dis. 2014;4(4):e68-75.
CDC. Investigational drug available directly from CDC for the treatment of infections with free-living amebae. MMWR Morb Mortal Wkly Rep. 2013;62(33):666.
Martínez DY, Seas C, Bravo F, Legua P, Ramos C, Cabello AM, Gotuzzo E. Successful treatment of Balamuthia mandrillaris amoebic infection with extensive neurological and cutaneous involvement.external icon Clin Infect Dis. 2010;51:e7-11.
Walochnik J, Obwaller A, Gruber F, Mildner M, Tschachler E, Suchomel M, Duchene M, Auer H. Anti-Acanthamoeba efficacy and toxicity of miltefosine in an organotypic skin equivalent.external icon J Antimicrob Chemother. 2009;64:539-45.
Kim JH, Jung SY, Lee YJ, Song KJ, Kwon D, Kim K, Park S, Im KI, Shin HJ. Effect of therapeutic chemical agents in vitro and on experimental meningoencephalitis due to Naegleria fowleri. pdf icon[PDF – 7 pages]external icon Antimicrob Agents Chemother. 2008;52:4010-6.
Aichelburg AC, Walochnik J, Assadian O, Prosch H, Steuer A, Perneczky G, Visvesvara GS, Aspöck H, Vetter N. Successful treatment of disseminated Acanthamoeba sp. infection with miltefosine. pdf icon[PDF – 4 pages]external icon Emerg Infect Dis. 2008;14:1743-6.
Soltow SM, Brenner GM. Synergistic activities of azithromycin and amphotericin B against Naegleria fowleri in vitro and in a mouse model of primary amebic meningoencephalitis. pdf icon[PDF – 5 pages]external icon Antimicrob Agents Chemother. 2007;51:23–7.
Schuster FL, Guglielmo BJ, Visvesvara GS. In-vitro activity of miltefosine and voriconazole on clinical isolates of free-living amebas: Balamuthia mandrillaris, Acanthamoeba spp., and Naegleria fowleri.external icon J Eukaryot Microbiol. 2006;53:121-6.
Vargas-Zepeda J, Gomez-Alcala AV, Vasquez-Morales JA, Licea-Amaya L, De Jonckheere JF, Lores-Villa F. Successful treatment of Naegleria PAM using IV amphotericin B, fluconazole, and rifampin.external icon Arch Med Res. 2005;36(1):83-6.
Schuster FL, Visvesvara GS. Free-living opportunistic and non-opportunistic pathogens of humans and animals.external icon Int J Parasitiol. 2004;34(9):1001-27.
Schuster FL, Visvesvara GS. Opportunistic amebae: challenges in prophylaxis and treatment.external icon Drug Resist Updat. 2004;7(1):41-51.
Deetz TR, Sawyer MH, Billman G, Schuster FL, Visvesvara GS. Successful treatment of Balamuthia amebic encephalitis: presentation of 2 cases.external icon Clin Infect Dis. 2003;37:1304-12.
Goswick SM, Brenner GM. Activities of azithromycin and amphotericin B against Naegleria fowleri in vitro and in a mouse model of primary amebic meningoencephalitis. pdf icon[PDF – 5 pages]external icon Antimicrob Agents Chemother. 2003;47:524-8.
Goswick SM, Brenner GM. Activities of therapeutic agents against Naegleria fowleri in vitro and in a mouse model of primary amebic meningoencephalitis.external icon J Parasitol. 2003;89(4):837-42.
Jain R, Prabhaker S, Modi M, Bhatia R, Sehgal R. Naegleria meningitis: A rare survival.external icon Neurol India. 2002;50(4):470-2.
Kaminsky R. Miltefosine Zentaris.external icon Curr Opin Investig Drugs. 2002;3(4):550-4.
Seidel J, Harmatz P, Visvesvara GS, Cohen A, Edwards J, Turner J. Successful treatment of primary amebic meningoencephalitis.external icon New Engl J Med. 1982;306:346-8.
Ferrante A. Comparative sensitivity of Naegleria fowleri to amphotericin B and amphotericin B methyl ester.external icon Trans R Soc Trop Med Hyg. 1982;76(4):476-8.
Lee KK, Karr SL Jr, Wong MM, Hoeprich PD. In vitro susceptibilities of Naegleria fowleri strain HB-1 to selected antimicrobial agents, singly and in combination.external icon Antimicrob Agents Chemother. 1979;16:217-20.

Roy SL, Metzger R, Chen JG, Laham FR, Martin M, Kipper SW, Smith LE, Lyon GM 3rd, Haffner J, Ross JE, Rye AK, Johnson W, Bodager D, Friedman M, Walsh DJ, Collins C, Inman B, Davis BJ, Robinson T, Paddock C, Zaki SR, Kuehnert M, DaSilva A, Qvarnstrom Y, Sriram R, Visvesvara GS. Risk for transmission of Naegleria fowleri from solid organ transplantation.external icon Am J Transplant. 2014;14(1):163-71.
Kramer MH, Lerner CJ, Visvesvara GS. Kidney and liver transplants from a donor infected with Naegleria fowleri.external icon J Clin Micro. 1997;35:1032-3.

Sarkar P, Gerba C. Inactivation of Naegleria fowleri by chlorine and ultraviolet light.external icon J AWWA. 2012;104(3):51-2.
Visvesvara G, Yoder J, Beach MJ. Primary amebic meningoencephalitis Chapter 73, pgs 442-7. In: Netter’s Infectious Diseases, Eds. Yong EC, Stevens DL. Elsevier Saunders. Philadelphia, PA. 2012.
Visvesvara GS, De Jonckheere JF, Sriram R, Daft B. Isolation and molecular typing of Naegleria fowleri from the brain of a cow that died of primary amebic meningoencephalitis.external icon J Clin Microbiol. 2005;43:4203-4.
Tiewchaloren S, Junnu V. Factors affecting the viability of pathogenic Naegleria species isolated from Thai patients. J Trop Med Parasitol. 1999;22:15-21.
Lozano-Alarcón F, Bradley GA, Houser BS, Visvesvara GS. Primary amebic meningoencephalitis due to Naegleria fowleri in a South American tapir.external icon Vet Pathol. 1997;34(3):239-43.
John DT, John RA. Cytopathogenicity of Naegleria fowleri in mammalian cell cultures.external icon Parasitol Res. 1989;76(1):20-5.
Robinson BS, Christy PE. Disinfection of water for control of amoebae. Water. 1984;September:21-4.
Rice EW, Hoff JC, Schaefer FW 3rd. Inactivation of Giardia cysts by chlorine. pdf icon[PDF – 2 pages]external icon Appl Environ Microbiol. 1982;43:250-1.
Jarroll EL, Bingham AK, Meyer EA. Effect of chlorine on Giardia lamblia cyst viability. pdf icon[PDF – 5 pages]external icon Appl Environ Microbiol. 1981;41:483-7.
Cursons RT, Brown TJ, Keys EA. Effect of disinfectants on pathogenic free-living amoebae: in axenic conditions. pdf icon[PDF – 5 pages]external icon Appl Environ Microbiol. 1980;40:62-6.
Chang SL. Resistance of pathogenic Naegleria to some common physical and chemical agents. pdf icon[PDF – 8 pages]external icon Appl Environ Microbiol. 1978;35:368-75.
Stevens AR, Tyndall RL, Coutant CC, Willaert E. Isolation of the etiological agent of primary amoebic meningoencephalitis from artificially heated waters. pdf icon[PDF – 5 pages]external icon Appl Environ Micro. 1977;34(6):701-5.
De Jonckheere J, van de Voorde H. Differences in destruction of cysts of pathogenic and nonpathogenic Naegleria and Acanthamoeba by chlorine. pdf icon[PDF – 4 pages]external icon Appl Environ Microbiol. 1976;31:294-7. (1 mg/l for an hour for cysts)
Griffin JL. Temperature tolerance of pathogenic and nonpathogenic free-living amoebas.external icon Science. 1972;178(4063):869-70.
SN Gustavo. Fatal primary amebic meningoencephalitis. A retrospective study in Richmond, Virginia.external icon Am J Clin Pathol. 1970;54:737-42.
Butt CG. Primary amebic meningoencephalitis.external icon N Engl J Med. 1966;274:1473-6.
Fowler M, Carter RF. Acute pyogenic meningitis probably due to Acanthamoeba sp.: a preliminary report. pdf icon[PDF – 4 pages]external icon Br Med J. 1965;2:740-2.

Waso M, Dobrowsky PH, Hamilton KA, Puzon G, Miller H, Khan W, Ahmed W. Abundance of Naegleria fowleri in roof-harvested rainwater tank samples from two continents.external icon Environ Sci Pollut Res. 2017. Epub ahead of print.
Marciano-Cabral F, Cabral G. The immune response to Naegleria fowleri amebae and pathogenesis of infection.external icon FEMS Immunol Med Microbiol. 2007;51(2):243-59.
Visvesvara GS, De Jonckheere JF, Marciano-Cabral F, Schuster FL. Morphologic and molecular identification of Naegleria dunnebackei n. sp. isolated from a water sample.external icon J Eukaryot Microbiol. 2005;52:523-31.

Cope JR, Murphy J, Kahler A, Gorbett DG, Ali I, Taylor B, Corbitt L, Roy S, Lee N, Roellig D, Brewer S, Hill VR. Primary amebic meningoencephalitis associated with rafting on an artificial whitewater river: case report and environmental investigation.external icon Clin Infect Dis. 2018;66(4):548-53.
DOI: 10.1093/cid/cix810
Cope JR, Conrad DA, Cohen N, Cotilla M, DaSilva A, Jackson J, Visvesvara GS. Use of the novel therapeutic agent miltefosine for the treatment of primary amebic meningoencephalitis: report of 1 fatal and 1 surviving case.external icon Clin Infect Dis. 2015;62(6):774-6.
Linam WM, Ahmed M, Cope JR, Chu C, Visvesvara GS, da Silva AJ, Qvarnstrom Y, Green J. Successful treatment of an adolescent with Naegleria fowleri primary amebic meningoencephalitis.external icon Pediatrics. 2015;135(3):e744-8.
Booth PJ, Bodager D, Slade TA, Jett S. Notes from the field: primary amebic meningoencephalitis associated with hot spring exposure during international travel — Seminole County, Florida, July 2014. MMWR Morb Mortal Wkly Rep. 2015;64(43):1226.
Cope JR, Ratard RC, Hill VR, Sokol T, Causey JJ, Yoder JS, Mirani G, Mull B, Mukerjee KA, Narayanan J, Doucet M, Qvarstrom Y, Poole CN, Akingbola OA, Ritter JM, Xiong Z, da Silva A, Roellig D, Van Dyke R, Stern H, Xiao L, Beach MJ. The first association of a primary amebic meningoencephalitis death with culturable Naegleria fowleri in tap water from a U.S. treated public drinking water system.external icon Clin Infect Dis. 2015;60(8):e36-42.
CDC. Primary amebic meningoencephalitis associated with ritual nasal rinsing — St. Thomas, U.S. Virgin Islands, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(45):903.
Yoder JS, Straif-Bourgeois S, Roy SL, Moore TA, Visvesvara GS, Ratard RC, Hill V, Wilson JD, Linscott AJ, Crager R, Kozak NA, Sriram R, Narayanan J, Mull B, Kahler AM, Schneeberger C, da Silva AJ, Beach MJ. Deaths from Naegleria fowleri associated with sinus irrigation with tap water: a review of the changing epidemiology of primary amebic meningoencephalitis.external icon Clin Infect Dis. 2012;1-7.
Shakoor S, Beg MA, Mahmood SF, Bandea R, Sriram R, Noman F, Ali F, Visvesvara GS, Zafar A. Primary amebic meningoencephalitis caused by Naegleria fowleri, Karachi, Pakistan. pdf icon[PDF – 4 pages]external icon Emerg Infect Dis. 2011:17;258-61.
CDC. Primary amebic meningoencephalitis—Arizona, Florida and Texas, 2007. MMWR Morb Mortal Wkly Rep. 2008;57(21):573-7.
CDC. Primary amebic meningoencephalitis—Georgia, 2002. MMWR Morb Mortal Wkly Rep. 2003;52(40):962-4.
CDC. Primary amebic meningoencephalitis—North Carolina, 1991. MMWR Morb Mortal Wkly Rep. 1992;41(25):437-40.
CDC. Primary amebic meningoencephalitis—California, Florida, New York. MMWR Morb Mortal Wkly Rep. 1978;27:343-4.

Page last reviewed: September 29, 2020

Content source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Foodborne, Waterborne, and Environmental Diseases (DFWED)