1. 1 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

2. 2 Outline of Presentation Description of outbreak Results Action taken Discussion –Issues arising –Lessons learned

3. 3

4. 4 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

5. 5 Epidemic Curve

6. 6 Descriptive Epidemiology 31 laboratory confirmed cryptosporidiosis 18 females, 13 males: 8 cases hospitalised

7. 7 Geographical Distribution of Cases

8. 8 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

9. 9 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

10. 10 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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12. 12 Issues arising Water Advice to vulnerable populations Communication

13. 13 Cryptosporidium species Faecal –C. hominis Water –C. parvum –C. andersoni –C. muris Implications – reassurance? –Intermittent excretion, small dose infective dose –Immunocompromised –Evidence of breakthrough

14. 14 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

15. 15 Cryptosporidium

16. 16 Source: Carlow County Council Clostridium perfringens

17. 17 C. perfringens and Cryptosporidium

18. 18 In line turbidity of filter outletGrab sample of final water turbidity Standard 1 NTU Turbidity Source: Carlow County Council

19. 19 Rainfall levels & onset of illness

20. 20 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

21. 21 Communication Proactive –Council meetings –Press interviews –Notice distribution and updates –Helpline –Website –FAQs –Links Website www.carlow.iewww.carlow.ie

22. 22 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

23. 23 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.

24. 24 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