United States
Environmental Protection
Agency
Contaminant Candidate List 3
Microbes: PCCL to CCL Process
Office of Water (4607M) EPA 815-R-08-007 February 2008 - Draft www.epa.gov/safewater
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Contents
Abbreviations and Acronyms 1
1.0 Background and Scope 1
2.0 Rationale Used to Develop Scoring Protocols 2
3.0 Selecting the CCL from the Ranked PCCL 10
4.0 Scoring Data Sheets 11
Exhibits
Exhibit 1. Waterborne Disease Outbreak Scoring Protocol 4
Exhibit 2. Occurrence Scoring Protocol for Pathogens 5
Exhibit 3. Health Effects Scoring Protocol for Pathogens 7
Exhibit 4. Health Effects Scores for PCCL 9
Exhibit 5. Draft CCL3 Microbes 10
11
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Abbreviations and Acronyms
ARD - Acute Respiratory Disease
CCL - Contaminant Candidate List
CCL 3 - EPA's Third Contaminant Candidate List
CDC - Centers for Disease Control and Prevention
EPA - United States Environmental Protection Agency
EVs - Enteroviruses
HUS - Hemolytic-uremic syndrome
MMWR - Morbidity and Mortality Weekly Report
NDWAC - National Drinking Water Advisory Committee
NPDWR - National Primary Drinking Water Regulation
NRC - National Research Council
PCCL - Preliminary Candidate Contaminant List
PCR - Polymerase Chain Reaction
PWS - Public Water System
SAB - Science Advisory Board
SDWA - Safe Drinking Water Act
USEPA - United States Environmental Protection Agency
WBDO - Waterborne Disease Outbreak
US - United States of America (includes territories)
CCL 3 Microbes: PCCL to CCL Process
1.0 Background and Scope
The scoring process discussed in this document is the last step in a three-step process
designed to select microbial contaminants for the third Contaminant Candidate List (CCL 3).
The first step of the process is identification of a universe of potential drinking water
contaminants. The document titled, Contaminant Candidate List 3 Microbes: Identifying the
Universe provides a summary of the statutory and regulatory background leading to development
of a microbial CCL and describes the activities required to develop a microbial CCL universe as
the initial step in a transparent and scientifically sound CCL process.
A second document titled, Contaminant Candidate List 3 Microbes: Screening to the
PCCL., describes a process to screen human pathogens from a universe of microbiological
contaminants for placement on the Preliminary Contaminant Candidate List (PCCL) as the
second step in the CCL process. The universe of pathogens is screened based on the likelihood
to be present in drinking water and that are associated with illness attributable to drinking water
exposure.
In this third step of the CCL 3 process the PCCL pathogens are evaluated for their
occurrence in drinking water, and their ability to produce adverse health effects in humans.
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Pathogens on the PCCL were scored for placement on CCL 3. EPA devised a scoring system to
assign a numerical value to each pathogen on the PCCL. Pathogens receiving high scores are
considered for placement on the CCL 3.
This document describes the set of scoring protocols used to relatively rank pathogens on
the PCCL to produce CCL 3. EPA derived this scoring process in part from recommendations of
the National Research Council and an expert workgroup established by the National Drinking
Water Advisory Council, and two external workshops (June 2006 and March 2007). This
document describes the rationale for using scoring protocols to rank pathogens based upon their
occurrence, health effects, and waterborne disease outbreaks.
2.0 Rationale Used to Develop Scoring Protocols
Section 1412(b)(l) of SDWA, as amended in 1996, specifies that the list must include
contaminants that are not subject to any proposed or promulgated NPDWRs, are known or
anticipated to occur in public water systems (PWSs), and may require regulation under SDWA
(adverse health effects). The objective is to target microorganisms with the highest potential for
exposure and the most serious adverse human health effects.
Each of the pathogens on the PCCL was scored using three scoring protocols, one
protocol each for waterborne disease outbreaks (WBDO), occurrence in drinking water, and
health effects. The higher of the WBDO score or the occurrence score is added to the
normalized health effects score to produce a composite pathogen score. Pathogens receiving
high scores were considered for placement on the CCL 3.
Occurrence data includes public health surveillance, molecular techniques, culture-based
methods and can be collected as part of public health surveillance, response to a disease outbreak
or in connection with research efforts. Evaluating these many types of information is a major
challenge in developing the CCL selection process.
Public health surveillance programs and the scientific literature provided a range of
exposure information from multiple documented microbial outbreaks to microbes that have
limited associations to outbreaks. The sources of information ranged from Centers for Disease
Control and Prevention (CDC) to studies identified from the scientific literature.
The CCL 3 selection process considered pathogens causing recent waterborne outbreaks
more important than pathogens detected in drinking water without documented disease from that
exposure. Direct detection of pathogens indicates the potential for waterborne transmission of
disease. Documented waterborne disease outbreaks provide an additional weight of evidence
that illness was transmitted and that there was a waterborne route of exposure. EPA developed
protocols to define a hierarchy of the relevance that each of these types of data provide in
evaluating microbes for CCL 3. Combining these two sources of occurrence information
enabled EPA to consider both emerging pathogens that should be considered and are not yet
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tracked by public health surveillance programs and WBDO data. This hierarchy also
acknowledges that organisms identified as agents in WBDO are a higher priority for the CCL 3.
The combination of documented waterborne disease outbreak data and direct detection
data identified and relatively compares organisms that should be considered for CCL 3 based on
occurrence. The evaluation of potential occurrence still needed to be balanced against the
possible adverse health effects from that exposure. The severity of the disease should also
inform the decision of whether or not to list a microbe on CCL 3. Organisms that may be linked
to widespread outbreaks of moderate illness (i.e., self-limiting gastrointestinal illness) or
organisms that results in debilitating disease (i.e., hepatitis or death) from drinking water
exposure are considered for CCL 3.
The assumptions used to develop the CCL 3 scoring process are as follows:
• WBDO data and direct detection of pathogens provide occurrence data that can and
should be organized into a hierarchy to evaluate microbes, and
• Combining health effects data with the WBDO/occurrence data provides a system that
evaluates both the severity of potential disease and the potential magnitude of exposure
through drinking water.
2.1 Waterborne Disease Outbreaks
WBDOs are the documentation of occurrence of pathogens in drinking water by public
health officials through adverse health effects in a population and are direct evidence of
exposure. For a WBDO to occur an infective dose must be present in water and a susceptible
person must be exposed, resulting in clinical manifestations of disease. Recognition of pathogens
causing WBDOs is important to the CCL 3 selection process. Because water-related illness may
also occur in the absence of recognized outbreaks, the process has been broadened to include
recreational water exposures and other exposures if the source of a pathogen is traced to a public
drinking water system. Epidemiological investigation must implicate a drinking water source as
the probable cause of the outbreak. Recreational water settings include swimming pools, and
spas if they were filled with drinking water from a public water system (as defined by the Safe
Drinking Water Act). EPA excluded non-drinking water sources such as marine and estuarine
water bodies from consideration under the CCL 3.
The Centers for Disease Control and Prevention (CDC), EPA and the Council of State
and Territorial Epidemiologists (CSTE) have maintained a collaborative surveillance system for
collecting and periodically reporting data related to occurrences and causes of WBDOs since
1971. EPA used the CDC surveillance system as the primary source of data for the waterborne
disease outbreaks protocol. Reports from the CDC system are published periodically in
Morbidity and Mortality Weekly Report (MMWR).
For this protocol, a pathogen is scored as having a WBDO(s) in the US if that pathogen is
listed in a CDC waterborne disease drinking water surveillance summary (i.e., in the MMWR).
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A pathogen with multiple WBDOs listed by CDC is given the highest score under this protocol.
EPA also scored non-CDC reported WBDOs and WBDOs outside the U.S. as well; however,
these were given lower scores. WBDOs outside the U.S. were scored when information was
available from World Health Organization publications or other peer reviewed publications.
In addition, CDC and EPA acknowledge that the WBDOs reported in the surveillance
system represent only a portion of the burden of illness associated with drinking water exposure
(CDC, 2004). The surveillance information does not include endemic waterborne disease risks,
and reliable estimates of the number of unrecognized WBDOs are not available.
Therefore, EPA also considered data as indicating a WBDO (even though CDC does not
list a WBDO in their MMWR) if the non-CDC data showed a link between human illness
defined by a common water source, a common time period of exposure and/or similar symptoms.
EPA also considered the use of molecular typing methods to link patients and environmental
isolates. Only the following two pathogens were given a WBDO score based on U.S. data not
listed in CDC's MMWR: Mycobacterium avium and Arcobacter butzlerei.
The WBDO scoring protocol also uses the CDC definition for outbreak as two or more
persons epidemiologically linked by location of exposure to water, time, and illness (CDC,
2006). CDC excludes single cases of illness from the definition of WBDO except for single
cases of Naegleria fowleri (causing primary amebic meningoencephalitis) and Vibrio cholerae.
Exhibit 1. Waterborne Disease Outbreak Scoring Protocol
Category
Has caused multiple (2 or more) documented WBDOs in US since CDC surveillance
initiated in 1973
Has caused at least one documented WBDOs in US since CDC surveillance initiated in
1973
Has caused documented WBDOs at any time in the US
Has caused documented WBDO in countries other than the US
Has never caused WBDOs in any country, but has been epidemiologically associated with
water related disease
Score
5
4
3
2
1
2.2 Occurrence
The occurrence attribute is the direct detection of microbes using cultural,
immunochemical, or molecular detection of pathogens in water. It characterizes pathogen
introduction, survival, and distribution in the environment. Occurrence implies that pathogens
are present in water and that they may be capable of surviving and moving through water to
produce illness in persons exposed to water by ingestion, inhalation, or dermal contact.
Pathogen occurrence is considered broadly to include public drinking water, and all
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waters using a drinking water source for recreational purposes, ground water, and surface water.
This attribute does not characterize the extent to which occurrence of a pathogen poses a public
health threat from drinking water exposure. Because viability and infectivity cannot be
determined by non-cultural methods, the public health significance of non-cultural detections is
unknown.
Exhibit 2. Occurrence Scoring Protocol for Pathogens
Category
Detected in drinking water in the US
Detected in source water in the US
Not detected in the US
Score
O
2
1
2.3 Health Effects
The health effects protocol evaluates the extent of illness produced in humans from
drinking water or recreational water exposure. The severity of disease manifestations produced
by a pathogen is evaluated across a range of potential endpoints. The seven level hierarchy
developed for this protocol begins with mild, self-limiting illness and progresses to death.
The Agency tried to evaluate the potency of an organism, i.e., the concentration of a
pathogen during exposure that is necessary to cause illness in a susceptible host (infectious
dose). However, infectious doses are not available for many pathogens. Characterizing the
attribute of health effects considers the extent of exposure necessary to produce disease and
resulting manifestations of disease in a susceptible host. The Agency uses this health effect
protocol to score both the severity of disease and the organisms' potency with the best available
data.
The final outcome of a host-pathogen relationship resulting from drinking water exposure
is a function of viability, infectivity, and pathogenicity of the microbe to which the host is
exposed and the host's susceptibility and immune response. SDWA directs EPA to consider
subgroups of the population at greater risk of adverse health effects (sensitive populations) in the
selection of unregulated contaminants for the CCL. Sensitive populations may have increased
susceptibility and may experience increased severity of symptoms, compared to the general
population. SDWA refers to several categories of sensitive populations including the following:
children and infants, elderly, pregnant women, and persons with a history of serious illness.
Health effects for individuals with marked immunosuppression (e.g., primary or acquired
severe immunodeficiency, transplant recipients, individuals undergoing potent cytoreductive
treatments) are not included in this health effects scoring. While such populations are
considered sensitive subpopulations, immunosuppressed individuals often have a higher standard
of ongoing health care and protection required than the other sensitive populations under medical
care. More importantly, nearly all pathogens have very high health effect scores for the markedly
immunosuppressed individuals; therefore there is little differentiation between pathogens based
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on health effects for the immunosuppressed subpopulation.
This protocol scores the representative or common clinical presentation for the specific
pathogen for the population category under consideration. Pathogens may produce a range of
illness from asymptomatic infection to fulminate illness progressing rapidly to death. The
scoring decisions are based upon the more common clinical presentation and clinical course for
the population under consideration, rather than the extremes. EPA used recently published
clinical microbiology manuals as the primary data source for the common clinical presentation.
These manuals take a broad epidemiological view of health effects rather than focusing on
narrow research investigations or single cases. The one exception to this approach was EPA's
scoring of health effects for Helicobacter pylori.
Helicobacter pylori is a pathogen that causes gastric cancer in addition to acute gastric
ulcers. EPA placed this pathogen on the draft CCL 3. However, the analysis for H. pylori
differs from the other pathogens due to the long term and/or chronic nature of its health effects
rather than the more common acute effects of most waterborne pathogens. This organism is an
emerging pathogen whose impact has only recently begun to be understood. Given the slow
development of adverse health effects due to infection by H. pylori, it is more difficult to link
contamination of drinking water and show a waterborne disease outbreak. Therefore, given the
long timeframe of cancer and ulcer development (as opposed to the commonly acute
gastrointestinal illness of nearly all the other pathogens on the PCCL) as well as the ongoing
nature of the research, EPA used peer-reviewed scientific papers to score the health effects of//.
pylori. The data used to score H. pylori is cited in scoring data sheets at the end of this
document.
To obtain a representative characterization of health effects in all populations, EPA
evaluated separately the general population and the four sensitive populations (see exhibit 3) on
the common clinical presentation of illness for each population. EPA added the general
population score to the highest score among the four sensitive subpopulations for an overall
health effects score. The resulting score acknowledges that sensitive populations have increased
risk for waterborne diseases.
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Exhibit 3. Health Effects Scoring Protocol for Pathogens
Outcome Category
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization
(> week)?
Does the illness result in
long term or permanent
dysfunction or disability
(i.e., sequelae)?
Does the illness require short
term hospitalization
(
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Pathogens are first scored using the WBDO and occurrence protocols, and then the
highest score is selected. Selection of the higher score from the WBDO or occurrence protocol
elevates pathogens that have been detected in drinking water or source water in the U.S.
(occurrence score of 2 or 3) above pathogens that have caused WBDOs in other countries but not
in the U.S. (WBDO score of 2) or pathogens that have not caused WBDOs in any country but
have been epidemiologically associated with water-related disease (WBDO score of 1). This
scoring protocol recognizes the importance of WBDO data in evaluating the public health risk
posed by pathogens in drinking water, while ensuring that pathogens that have been detected in
public water systems and have not been identified as causative agents WBDOs remain in the
CCL process.
Next, pathogens are scored using the health effects protocol. This protocol scores the
representative health effect characteristic of each pathogen for the general population, e.g.
noroviruses characteristically cause gastrointestinal symptoms that are self-limiting within two
days in otherwise healthy adults. All five population categories (general, child, elderly, pregnant
women and chronic disease) are scored for each pathogen using the most common clinical
presentation for the specific pathogen for the population category under consideration. The
lowest population score was used for any specific population for which health effects
information was not readily available. The pathogen's score for the general population is added
to the highest score among the four sensitive populations to produce a sum score between 2 and
14.
Finally, EPA normalizes the Health Effects and WBDO/Occurrence score because the
Agency believes they are of equal importance. The highest possible score for WBDO/Occurence
is 5 and the highest possible Health Effect score is 14. To equalize this imbalance, the Agency
multiplies the combined score by 5/14.
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Exhibit 4. Health Effects Scores for PCCL
Pathogen
Naegleria fowleri
Legionella
pneumophila
Escherichia coli
(0157)
Hepatitis A virus
Shigella sonnei
Helicobacter
pylori
Campylobacter
jejuni
Salmonella
enterica
Caliciviruses
Entamoeba
histolytica
Vibrio cholerae
Adenovirus
Enterovirus
Cyclospora
cayetanensis
Mycobacterium
avium
Rotavirus
Yersinia
enterocolitica
Arcobacter
butzleri
Fusarium solani
Plesiomonas
shigelloides
Hepatitis E virus
Toxoplasma
gondii
Aspergillus
fumigat us group
Exophiala
jeanselmei
Aeromonas
hydrophila
Astro virus
Microsporidia
Isospora belli
Blastocystis
hominis
WBDO
4
5
5
5
5
1
5
5
5
5
5
2
2
4
4
4
5
4
1
4
2
2
1
1
1
2
1
2
1
Occur.
3
3
3
2
3
3
3
3
3
3
3
3
3
1
3
2
3
3
3
3
1
1
3
3
3
2
2
0
0
Health Effects
Gen.
7
4
3
3
3
7
3
3
2
3
3
6
4
3
3
1
2
3
4
2
3
2
3
3
2
2
2
1
1
Child
7
4
6
3
6
3
4
4
4
3
3
4
6
4
3
6
2
3
4
3
3
2
3
3
3
2
2
2
1
Elderly
7
6
6
6
6
7
4
4
4
3
3
2
2
3
3
1
2
3
4
3
6
2
3
3
2
2
2
1
1
Pregnant
Women
7
4
3
3
3
3
3
3
2
3
3
2
2
3
3
1
2
3
4
2
7
7
3
3
2
2
2
1
1
Chronic
Disease
7
6
3
3
3
3
3
3
4
3
3
4
2
3
4
1
2
3
4
2
3
2
3
3
2
2
2
1
1
Normalized
Health
5.0
3.6
3.2
3.2
3.2
5.0
2.5
2.5
2.1
2.1
2.1
3.6
3.6
2.5
2.5
2.5
1.4
2.1
2.9
1.8
3.6
3.2
2.1
2.1
1.8
1.4
1.4
1.1
0.7
Total
Score
9.0
8.6
8.2
8.2
8.2
8.0
7.5
7.5
7.1
7.1
7.1
6.6
6.6
6.5
6.5
6.5
6.4
6.1
5.9
5.8
5.6
5.2
5.1
5.1
4.8
3.4
3.4
3.1
1.7
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3.0 Selecting the CCL from the Ranked PCCL
The scoring system involves selecting a pathogen and completing three scoring protocols,
one protocol each for WBDOs and Occurrence, and one protocol for normal populations and
four sensitive populations (children, elderly, pregnant women, and persons with chronic
diseases). The higher of the WBDO score or the occurrence score is added to the normalized
health effects score to produce a composite pathogen score. This process results in a ranked list
of pathogens from which those the Agency may select for placement on a CCL 3.
The scoring process developed by EPA ranks microbial drinking water contaminants in a
transparent and scientifically sound manner. The weighing of occurrence and health effects
information closely mirrors the risk estimate methods used by EPA during drinking water
regulation development. This scoring system will prioritize and restrict the number of pathogens
on a CCL 3 to only those that have been strongly associated with water-related diseases.
Pathogens failing to meet these criteria will remain on the PCCL until additional occurrence
data, epidemiological surveillance data, or health effects data support their reevaluation.
The 29 PCCL pathogens are ranked according to an equal weighting of their summed
scores for normalized health effects and the higher of the individual scores for WBDO and
occurrence in drinking water. EPA believes this ranking indicates the most important pathogens
to consider for the draft CCL 3. To determine which of the 29 PCCL pathogens should be the
highest priority for EPA's drinking water program and included on the draft CCL 3, the Agency
considered both scientific and policy factors. The factors included the PCCL scores for WBDO,
occurrence, and health effects; comments and recommendations from the various expert panels;
the specific intent of SDWA; and the need to focus Agency resources on pathogens to provide
the most effective opportunities to advance public health protection. After consideration of these
factors, EPA has determined that the draft CCL 3 will include the 11 highest ranked pathogens.
Additionally, there are a few "natural" break points in the ranked scores for the 29
pathogens, with the top 11 forming the highest ranked group of pathogens. EPA does believe
that the overall rankings strongly reflect the best available scientific data and high quality expert
input employed in the CCL selection process, and therefore should be important factors in
helping to identify the top priority pathogens for the draft CCL 3.
Exhibit 5. Draft CCL3 Microbes
• Caliciviruses
• Campylobacter jejuni
• Entamoeba histolytica
• Escherichia coli (0157)
• Helicobacter pylori
• Hepatitis A virus
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• Legionella pneumophila
• Naegleria fowleri
• Salmonella enterica
• Shigella sonnei
• Vibrio cholerae
4.0 Scoring Data Sheets
This section contains a scoring sheet for each of the pathogens on the PCCL. The
scoring sheets are arranged alphabetically by pathogen.
A score for each protocol (WBDOs and occurrence, and health effects) is determined.
Bolded text in each protocol box indicates that is the protocol level that was scored for that
pathogen. For example, if the question "Detected in drinking water in the U.S.?" under the
occurrence protocol is bolded than that organism received the occurrence score (i.e., 3). The
higher of the WBDO score or the occurrence score is added to the normalized health effects
score to produce a composite pathogen score. References for each scoring discussion are
provided. Health effects scoring involved scoring for each of 5 populations: General (G),
Children/infants (C), Elderly (E), Pregnant Women (P), and persons with Chronic Disease (CD).
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Adenovirus Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the
U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
Yes
Outbreaks in Europe.
N/A
USEPA, 2007
CDC, 2004; CDC; 2006;
Craun et al., 2003
Kukkula et al., 1997
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
PCR in connection with an
outbreak.
Yes, 38% of surface water
samples collected as part of
the Information Collection
Rule contained Adenovirus
40/41.
N/A
O'Reilly et al, 2007
Fong et al., 2007
USEPA, 2007
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
No
[G] A frequent cause of
pneumonia among
Gray et al., 2001
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Data Element
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require
short term hospitalization (<
week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
(unvaccinated) military
recruits. Two deaths in
previously-healthy adults
ARD is still a significant
problem in military. Less
common manifestations
include fatal neonatal
disease, meningoencephalitis
and myocarditis.
No
[CD] Children with chronic
disease required respiratory
ventilation.
[C] Young adults may
contract acute respiratory
disease.
Physician office visits are
indicated for ocular infections
[E, P] Approximately 50%
of cases are asymptomatic;
symptomatic cases usually
present as upper respiratory
infections similar to the
common cold.
N/A
Reference
Robinson in Murray 2007
CDC, 1983
CDC, 1998
Robinson in Murray 2007
Robinson in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 1983. Adenovirus type 7 outbreak in a pediatric chronic-care facility - Pennsylvania.
1972. MMWR, 1983:32;258-60.
CDC, 1998. Civilian Outbreak of Adenovirus Acute Respiratory Disease - South Dakota, 1997.
MMWR 1998: 47(27);567-570.
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CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003— 2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Fong, T., L. Mansfield, D. Wilson, D. Schwab, S. Molloy and J. Rose. 2007. Massive
Microbiological Groundwater Contamination Associated with a Waterborne Outbreak in Lake
Erie, South Bass Island, OH. Environmental Health Perspectives.
Kukkula, M., Arstila P., Klossner M., Maunula L., Bonsdorff C., and P. Jaatinen. 1997.
Scandinavian Journal of Infectious Disease, 29(4):415-8.
Gray, G., P. Goswami, M. Malasig, A. Hawksworth, D. Trump, M. Ryan and D. Schnurr. 2001.
Adult Adenovirus Infections: Loss of Orphaned Vaccines Precipitates Military Respiratory
Disease Epidemics. Clinical Infectious Diseases, 31:663-70.
O'Reilly, C., A. Bowen, E. Nytzia, J. Sarisky, C. Shepherd, M. Miller, B. Hubbard, M. Herring,
S. Buchanan, C. Fitzgerald, V. Hill, M. Arrowood, L. Xiao, R. Hoekstra, E. Mintz, M. Lynch,
and the Outbreak Working Group. 2007. A Waterborne Outbreak of Gastroenteritis with
Multiple Etiologies among Resort Island Visitors and Residents: Ohio, 2004. Clinical Infectious
Diseases, 44:506-512.
Robinson, C. and M. Echavarria. 2007. Adenoviruses. In Murray, P., E. Baron, J. Jorgensen, M.
Landry, and M. Pfaller (ed.) The Manual of Clinical Microbiology, 9th. edition, American
Society for Microbiology, Washington, DC. Vol. 2: p. 1592.
USEPA. 2007. Adenovirus Health and Criteria Document (Draft).
14
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Aeromonas hydrophila Scoring Data
Bolded Text indicates data used to score
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
No
Yes
CDC, 2004; CDC; 2006;
Craun et al., 2003
Gavriel et al, 1998
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
EPA found A. hydrophila in
the distribution systems of
42 out of 293 public water
systems tested.
Yes
N/A
EPA, 2006 and EPA, 2003
Holmes etal., 1996
EPA, 2006
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Wound infections are usually
preceded by injury that occurs
in contact with water. These
infections range from cellulitis
to myronecrotic infections
Horneman in Murray 2007
15
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Data Element
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
with a poor prognosis.
Septicemia occurs rarely in
immunocompetent hosts. Can
cause HUS.
[C] Children may require
hopitalization due to
dehydration
[G, P, E, CD] Acute watery
diarrhea is the most
common form as well as
abdominal pain, vomiting,
fever.
N/A
Reference
Horneman in Murray 2007
Horneman in Murray 2007
Horneman in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
16
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EPA. 2006 Aeromonas: Human Health Criteria Document. Page 136.
http://www.epa.gov/waterscience/criteria/humanhealth/microbial/aeromonas-200603.pdf.
EPA, 2003. Unpublished data on occurrence results from the Unregulated Contaminant
Monitoring Rule, http://www.epa.gov/safewater/ucmr/data.html. See 70 FR 49094, August 22,
2005 for more information.
Gavriel, A., J. Landre, and A. Lamb. 1998. Incidence of mesophilic Aeromonas within a public
drinking water supply n Northeast Scotland. Journal of Applied Bacteriology 84:383-392.
Holmes, P., L. Niccolls, and D. Sartory. 1996. The ecology of mesophilic Aeromonas in the
aquatic environment. In Austin, B., M. Altwegg, P. Gosling, and S. Joseph, ed. The Genus
Aeromonas. John Wiley & Sons, Chichester, UK.
Horneman, A., A. Ali and S. Abbott. 2007. Aeromonas. In Murray, P., E. Baron, J. Jorgensen,
M. Landry, and M. Pfaller (ed.) The Manual of Clinical Microbiology, 9th. edition, American
Society for Microbiology, Washington, DC. Vol. 1: p.717.
17
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Arcobacter butzleri Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
Yes
Not listed by CDC MMWR,
however, linked to outbreak
and drinking water.
Presumptive Campylobacter
stool samples later
Arcobacter. Symptom
severity also suggests
Arcobacter
N/A
N/A
N/A
CDC, 2004; CDC; 2006;
Craun et al., 2003
Fong et al., 2007
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes, Arcobacter butzleri was
isolated from ground water in
Idaho after a WBDO.
N/A
Fong, etal, 2007
Riceetal., 1999.
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
Unknown
Persons with underlying
disease such as liver disease,
Hsuehetal., 1997
Lerneretal., 1994
18
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Data Element
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
cirrhosis, or alcoholism may
be at increased risk of
complications.
Has been isolated from
patients with bacteremia,
endocarditis, peritonitis and
diarrhea. Clinical significance
unknown.
[All populations] Displays
clinical features similar to
Campylobacterjejuni,
however is more frequently
associated with a persistent
diarrhea. 26 percent of
Belgian patients required
antibiotics.
[G] Usual symptoms are
diarrhea, abdominal pain,
vomiting, and nausea
resolving in < 3 days.
N/A
Reference
Yanetal., 1999
Fitzgerald in Murray 2007
Vandenberg, et al., 2004
Wybo et al., 2004
Riceetal., 1999
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001— 2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003— 2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
19
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Fitzgerald, C. and I. Nachamkin. 2007. Campylobacter and Arcobacter. In Murray, P., E.
Baron, J. Jorgensen, M. Landry, and M. Pfaller (ed.) The Manual of Clinical Microbiology, 9th.
edition, American Society for Microbiology, Washington, DC. Vol. 1: pp. 933 -935.
Fong, T., L. Mansfield, D. Wilson, D. Schwab, S Molloy and J Rose. 2007. Massive
Microbiological Groundwater Contamination Associated with a Waterborne Outbreak in Lake
Erie, South Bass Island, OH. Environmental Health Perspectives.
Hsueh, P., L Teng, P. Yang, S. Wang, S. Chang, S. Ho, W. Hsieh and K. Luh. 1997. Bacteremia
caused by Arcobacter cryaerophilus IB. Journal of Clinical Microbiology 35(2): 489-491.
Lerner, J., V. Brumberger and V. Preac-Mursic. 1994. Severe diarrhea associated with
Arcobacter butzleri. European Journal of Clinical Microbiology & Infectious Diseases 13(8):
660-662.
Rice, E. W., M. R. Rodgers, I. V. Wesley, C. H. Johnson, and S. A. Tanner. 1999. Isolaton of
Arcobacter butzleri from ground water. Lett. Appl. Microbiol. 28:31-35.
Vandenberg, O., A. Dediste, K. Houg, S. Ibekwen, H. Souayah, S. Cadranel, N. Douat, G. Zissis,
J. Butzler and P. Vandamme. 2004. Arcobacter Species in Humans. Emerging Infectious
Diseases. Vol. 10, No. 10, page 1863, October 2004.
Wybo, I, J. Breynaert, S. Lauwers, F. Lindenburg, and K. Houf. 2004. Isolation of Arcobacter
skirrowii from a patient with chronic diarrhea. Journal of Clinical Microbiology 42(4): 1851-
1852.
Yan, J., W. Ko, A. Huang, H. Chen, Y. Jin and J. Wu. 1999. Arcobacter butzleri bacteremia in
a patient with liver cirrhosis. Journal of the Formosan Medical Association 99(2): 166-169.
20
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Aspergillus fumigatus Scoring Data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
No
Yes
Study on two bone marrow
transplantation units at a
Little Rock, AR hospital.
CDC, 2004; CDC; 2006;
Craun et al., 2003
Anaissie et al., 2002
Anaissie et al., 2003
Warris et al., 2003
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes
N/A
Anaissie et al., 2002
Anaissie et al., 2003
Nagy and Olson, 1982
Rosenzweig et al., 1986
Doggett, 2000
Vesper et al., 2007
Nagy and Olson, 1982
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
Invasive infections caused by
Aspergillus species are
associated with high rates of
morbidity and mortality,
especially in
immunosuppressed patients.
Sporadic cases of invasive
Verweij and Brandt in Murray
2007
Bodey and Vartivarian, 1989
21
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Data Element
Scoring Data
Reference
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
aspergillosis have been
reported in immunocompetent
hosts (chronic meningitis,
endocarditis, pericarditis,
osteomyelitys).
Invasive aspergillosis is
primarily an infection of
severely
immunocompromi sed
patients.
Serious infection can also
occur in patients with more
modest impairments of host
immune system such as
diabetics.
Nagy and Olson 1982
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
None reported
Does the illness require short
term hospitalization (< week)?
Need for hospitalization
depends upon the
manifestation of disease, (e.g.
superficial skin and ear
infections do not require
hospitalization).
Bodey and Vartivarian, 1989
Does the illness require
physician intervention?
[All Populations] Most
infections and allergies
caused by this organism
require physician
intervention.
Bodey and Vartivarian, 1989
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
N/A
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Aspergillus spores are
allergens and persons who
become sensitized experience
symptoms of allergy and
22
Horneretal., 1995
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Data Element
Scoring Data
asthma.
Reference
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Anaissie, E., S. Stratton, M. Dignani, R. Summerbell, J. Rex, T. Monson, T. Spencer, M, Kasai,
A. Francesconi, and T. Walsh. 2002. Pathogenic Aspergillus species recovered from a hospital
water system: a 3-year prospectie study. Clin. Infect. Dis. 34:780-789.
Anaissie, E., S. Stratton, M. Dignani, C. Lee, R. Summerbell, J. Rex, T. Monson, and T. Walsh.
2003. Pathogenic molds (including Aspergillus species) in hospital water distribution systems: a
3-year prospective study and clinical implications for patients with hematologic malignancies.
Blood, 101(7): 2542-2546.
Bodey, G. and S. Vartivarian. 1989. Aspergillosis. Eur. J. Clin. Microbiol. Infect. Dis. 8(5):413-
437.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Doggett, M. 2000. Characterization of fungal biofilms within a municipal water distribution
system. Appl. Environ. Microbiol. 66(3): 1249-1251.
Horner, W., A. Helbling, J. Salvaggio, and S. Lehrer. 1995. Fungal allergens. Clin. Microbiol.
Rev. 8(2): 161-179.
Nagy, L. and B. Olson. 1982. The occurrence of filamentous fungi in drinking water distribution
systems. Can. J. Microbiol. 28:667-671.
Rosenzweig W., H . Minnigh, and W. Pipes. 1986. Fungi in potable water distribution systems.
JAWWA78(l):53-55.
Verweij, P. and M. Brandt. 2007. Aspergillus, Fusarium, and Other Opportunistic Moniliaceous
Fungi. In Murray, P., E. Baron, J. Jorgensen, M. Landry and M. Pfaller (ed.) Manual of Clinical
Microbiology, 9th. edition, American Society for Microbiology, Washington, DC (Vol. 2). pp:
1804-1818.
Vesper, S., M. Rogers, A. Neely and R. Haugland. 2007. Opportunistic Aspergillus pathogens
measured in home and hospital tap water by quantitative PCR (QPCR). Journal of Water and
23
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EPA-OGWDW CCL 3 Microbes: EPA 815-R-08-007
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Health 5(3): 427-431.
Warns, A., C. Klassen, J. Meis, M. de Ruiter, H. de Valk, T. G. Abrahamsen, P. Gaustaad, and
P. Verweij. 2003. Molecular epidemiology of Aspergillus fumigatus isolates recovered from
water, air, and patients shows two clusters of genetically distinct strains. J. Clin. Microbiol.
41(9):4101-4106.
24
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Astrovirus Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the
U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
None reported, however CDC
reported two outbreaks
attributed to ' small round-
structured viruses', and it is
possible these were
astroviruses, though they
could also be caused by
rotavirus, or enterovirus.
N/A
N/A
Yes (England and Wales)
Yes
CDC, 2004; CDC, 2006;
Craun et al., 2003
Smith et al., 2006
Gofti-Laroche et al., 2003
Occurrence
Detected in drinking water in
the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
No
Yes, Astrovirus was detected
in 15 of 29 samples collected
under the Information
Collection Rule.
Chapron et al., 2000
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
No
No
25
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Data Element
pneumonia, meningitis,
hepatitis, encephalitis,
Noendocarditis, cancer, or
other severe manifestations of
illness necessitating long term
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
No
No
No
[All populations]
Asymptomatic infections
common. Moderate self-
limiting gastroenteritis
(vomiting and diarrhea).
N/A
Reference
Farkas in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Chapron, C., N. Ballester, J. Fontaine, C. Frades, and A. Margolin. 2000. Detection of
astroviruses, enteroviruses, and adenovirus types 40 and 41 in surface waters collected and
evaluated by the information collection rule and an integrated cell culture-nested PCR procedure.
Appl. Environ. Microbiol. 66(6):2520-2525.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Farkas, T. and X. Jiang. 2007. Rotaviruses, Caliciviruses, Astroviruses, Enteric Adenoviruses,
and Other Diarrheic Viruses. In Murray, P. , E. Baron, J. Jorgensen, M. Pfaller, and R. Yolken
26
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EPA-OGWDW CCL 3 Microbes: EPA 815-R-08-007
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(ed.) The Manual of Clinical Microbiology, 9th edition, American Society for Microbiology,
Washington, DC Vol. 2; pp!454-1457.
Gofti-Laroche, L., B. Gratacap-Cavallier, D. Demanse, O. Genoulaz, J. -M. Segneurin, and D.
Zmirou. 2003. Are waterborne astrovirus implicated in acute digestive morbidity (E.M.I.R. A.
study)? J. Clin. Virol. 27:74-82.
Smith, A, M Reacher, W Smerdon, G. Adak, G Nichols and R. Chalmers. 2006. Oubreaks of
waterborne infectious intestinal disease in England and Wales, 1992-2003. Epidemiol. Infect.
134(6):1141-1149.
27
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Blastocystis hominis Scoring Data
Bolded Text indicates data used to score
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
No
Yes, drinking untreated
water has been associated
with infection.
CDC, 2004; CDC; 2006;
Craun et al., 2003
Leelayoova et al., 2004
Stenzel and Boreham, 1996
Taamasri et al., 2000
Occurrence
Detected in drinking water in
the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
No
No
No
Karanis, 2006
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
Does the illness result in long
No
No
No
28
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Data Element
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?
Scoring Data
No
No
Symptoms may be more
pronounced and prolonged in
immunocompromi sed;
neoplasia and abnormal
intestinal tract function
[All populations]
Pathogenicity of B. hominis
is controversial. Symptoms
may include diarrhea,
vomiting and abdominal
pain.
Reference
Leber in Murray 2007
Leber in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Karanis P. 2006 A review of an emerging waterborne medical important parasitic protozoan.
Jpn. J Protozool. Vol 39(1) .
Leelayoova, S., R. Rangsin, P. Taamasri, T. Naaglor, U. Thathaisong, and M. Mungthin. 2004.
Evidence of waterborne transmission of Blastocystis hominis. American Journal of Tropical
Medicine & Hygiene 70(6):658-662.
Leber, A. and S. Novak-weekley. 2007 Intestinal and Urogenital Amebae, Flagellates, and
Ciliates. In Murray, P., E. Baron, J. Jorgensen, M. Landry, and M. Pfaller (ed.) The Manual of
Clinical Microbiology, 9th. edition, American Society for Microbiology, Washington, DC. Vol.
2: pp. 2097-2099.
29
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Stenzel, D., and P. Boreham. 1996. Blastocystis hominis revisited. Clinical Microbiology
Reviews 9(4):563-584.
Taamasri, P., M. Mungthin, R. Rangsin, B. Tongupprakarn, W. Areekul, and S. Leelayoova.
2000. Transmission of intestinal blastocystosis related to the quality of drinking water. Southeast
Asian Journal of Tropical Medicine & Public Health 31(1): 112-117.
30
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EPA-OGWDW
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Calicivirus Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs
in the U.S. since CDC
surveillance initiated in
1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
Yes
9 (Norwalk) Community
outbreaks
16 (Norwalk)
Noncommunity outbreaks
1 (Norovirus) Community
N/A
N/A
N/A
N/A
Craun et al., 2003
CDC, 2004
CDC, 2006
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes, detection by PCR.
Yes, detected in ground water
by PCR.
N/A
Huffman et al., 2003
Borchardt et al., 2003
Fout et al., 2003
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
No
No long term sequelae have
been reported.
CDC, 2001
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Data Element
severe manifestations of
illness necessitating long term
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require
short term hospitalization (<
week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
No
[E, CD] (Norwalk) Although
rare, severe dehydration
can be fatal, with this
outcome occurring among
susceptible persons (e.g.,
older persons with
debilitiating health
conditions).
[C] Sappoviruses cause
disease mainly in children.
No
[G, P] Acute gastroenteritis.
Highly contagious, able to
cause large outbreaks and
environmentally stable.
No
Reference
CDC, 2001
CDC 2001; CDC 2003
Farkas in Murray et al.,
2007
Farkas in Murray et al.,
2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Borchardt, M., P. Bertz, S. Spencer, and D. Battigelli. 2003. Incidence of enteric viruses in
groundwater from household wells in Wisconsin. Appl. Environ. Micro 69:1172-1180.
CDC. 2001 Norwalk-like viruses: Public health consequences and outbreak management.
MMWR50(RR-9):1-18.
CDC. 2003. Managing acute gastroenteritis among children. MMWR 52(RR-16):1-16.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
32
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United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Farkas, T. and X. Jiang. 2007. Rotaviruses, Caliciviruses, Astroviruses, Enteric Adenoviruses,
and Other Diarrheic Viruses. In Murray, P. R., E. J. Baron, J. H. Jorgensen, M. A. Pfaller, and
R. H Yolken (ed.) The Manual of Clinical Microbiology, 9th edition, American Society for
Microbiology, Washington, DC Vol. 2; pp!454-1457.
Fout, G., B. Martinson, M. Moyer, and D. Dahling. 2003. A multiplex reverse transcription-PCR
method for detection of human enteric viruses in groundwater. Appl. Environ. Microbiol.
69:3158-3164.
Huffman, D., K. Nelson, and J. Rose. 2003. Calicivirus - an emerging contaminant in water:
state of the art. Environ. Engr. Sci. 20:503-515.
33
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Campylobacter jejuni Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs
in the U.S. since CDC
surveillance initiated in
1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
Yes
9 Community and 7
Noncommunity outbreaks
1 Noncommunity
2 Community outbreaks
1 Noncommunity
N/A
N/A
Yes. Finland.
N/A
Craun, 2003
CDC, 2004
CDC, 2006
Kuusi, 2005
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes
N/A
Sacks et al., 1986
O'Reilly, 2007
Carter etal., 1987
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
Death is uncommon.
Complications include
hepatitis, bacterimia
cholecystitis, pancreatitis,
nephritis, abortion and
Fitzgerald in Murray, 2007
Fitzgerald in Murray 2007
34
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Data Element
Scoring Data
Reference
severe manifestations of
illness necessitating long term
hospitalization (> week)?
neonatal sepsis, urinary tract
infection, meningitis and
septic arthiritis. Bacteremia
occur in 0.15% of intestinal
infections with elderly mostly
affected
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
N/A
Does the illness require
short term hospitalization (<
week)?
[C, E] Most cases do not
require hospitalization,
pediatric cases and elderly
are more likely to require
hospitalization than normal
adult cases.
The highest incidence is in
children and infants.
Bacteremia occurs at 1.5 per
1,000 cases with the highest
rate occurring in the elderly.
Fitzgerald in Murray, 2007
Does the illness require
physician intervention?
[G, P, CD] Guillain-Barre
syndrome, reactive arthritis.
Guillain-Barre 1/1000 cases.
Reactive arthritis 1/100
Fitzgerald in Murray, 2007
Altekruse et al., 1999
cases
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Duration 2-5 days, usually
self-limiting.
Several days to more than 1
week, self-limiting, relapse in
5-10% cases
Heymann 2005
Fitzgerald in Murray 2007
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Illnesses range from
asymptomatic to acute
diarrhea, abdominal pain,
malaise, and fever
Fitzgerald in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
35
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EPA-OGWDW CCL 3 Microbes: EPA 815-R-08-007
PCCL to CCL Process February 2008 - DRAFT
Altekruse, S., N. Stern, P. Fields, and D. Swerdlow. 1999. Campylobacter jejuni - An
Emerging Foodborne Pathogen. Emerging Infectious Diseases 5(1).
Carter, A., R. Pacha, G. Colark, and E. Williams. 1987. Seasonal occurrence of Campylobacter
spp. in surface waters and thieir correlation with standard indicator bacteria. Appl. Environ.
Microbiol. 53(3):523-526.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003— 2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Heymann. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Kuusi, M., J. Nuorti, M. Hanninen, M Koskela, V Jussila, E Kela, I Miettinen, P Ruutu. A large
outbreak of campylobacteriosis associated with a municipal water supply in Finland. Epidemiol
Infect. 2005 Aug;133(4):593-601
Fitzgerald, C. and I. Nachamkin. 2007. Campylobacter and Arcobacter. In Murray, P., E.
Baron, J. Jorgensen, M. Landry, and M. Pfaller (ed.) The Manual of Clinical Microbiology, 9th.
edition, American Society for Microbiology, Washington, DC. Vol. 1: pp. 933 -935.
O'Reilly, C., A. Bowen, N. Perez, J. Sarisky, C. Shepherd, M. Miller, B. Hubbard, M. Herring,
S. Buchanan, C. C. Fitzgerald, V. Hill, M. Arrowood, L. Xiao, R. Hoekstra, E. Mintz, F. Lynch,
and Outbreak Working Group. 2007. A Waterborne Outbreak of Gastroenteritis with Multiple
Etiologies among Resort Island Visitors and Residents: Ohio, 2004. Clinical Infectious
Diseases. 44(4): 506-512.
Sacks, J., S. Lieb, L. M. Baldy, S. Berta, C. Patton, M. C. White, W. Bigler, and J. Witte. 1986.
Epidemic campylobacteriosis associated with a community water supply. Am. J. Public Health
76(4):424-429.
36
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Cyclospora cayetanensis Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
Yes, one drinking water
associated outbreak
occurred in IL presumably
due to contamination of a
water storage tank by birds.
N/A
N/A
N/A
CDC, 2004; CDC; 2006;
Craun, G., et al., 2003
Occurrence
Detected in drinking water in
the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
No
No
Detected in drinking water
in Guatemala
Dowd et al., 2003
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
No
No
37
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Data Element
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require
short term hospitalization (<
week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
Guillain-Barre and Reiter
syndromes have been
reported.
[C] Most cases do not
required hospitalization,
infants may require
hospitalization for
rehydration therapy.
[G and all other
populations] can cause
diarrhea and biliary disease.
In patients not treated,
illness can be protracted
with relapsing symptoms.
Reference
Connor etal., 2001
Fisk et al., 2005
Lindsay in Murray 2007
Heymann 2005
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Connor, B. , E. Johnson, and R. Soave. 2001. Reiter Syndrome Following Protracted Symptoms
of Cyclospora Infection. Emerging Infectious Disease. CDC. Volume 7, No. 3 May-June, 2001.
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18 ed. American Public
Health Association, Washington, DC.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
38
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Dowd, E., D. John, J. Eliopolus, C. Gerba, J. Naranjo, R. Klein, B. Lopez, M. de Mejia, C.
Mendoza and I. Pepper. 2003. Confirmed detection ofCyclospom cayetanesis, Encepalitozoon
intestinalis and Cryptosporidium parvum in water used for drinking. Journal of Water and
Health 01.3 117-123.
Fisk, T., J. Keystone, and P. Kozarsky.2005. In Mandel, G., J. Bennett, and R. Dolin Ed.
Mandel, Douglas and Bennett's Principles and Practice of Infectious Diseases, 6th Ed., Elsevier,
Philadelphia.
Lindsay, D., S. Upton and L. Weiss. 2007. Isospora, cyclospora and Sarcocystis. In Murray, P.,
E. Baron, J. Jorgensen, M. Pfaller, and R. Yolken (ed.) The Manual of Clinical Microbiology, 9th
edition, American Society for Microbiology, Washington, DC Vol. 2; pp 2113-2117.
39
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Entamoeba histolytica Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs
in the U.S. since CDC
surveillance initiated in
1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
Yes
1 Community outbreak
1 Community outbreak
1 Noncommunity outbreak
N/A
N/A
N/A
N/A
Craun, 2003
CDC, 2006
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes. Found during WBDO.
N/A
N/A
CDC, 2006
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
500 million infected (dispar
and histolytica) each year with
approximately 50 million
cases of colitis and liver
abscess and 100,000 deaths
worldwide.
Infections in the U.S. rarely
progress to complications,
amebic colitis may result in
Leber, in Murray 2007
Heymann, 2005
40
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EPA-OGWDW
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Data Element
Scoring Data
Reference
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
perforation of the intestinal
wall, resulting in peritonitis,
dissemination to
extraintestinal sites may
involve the liver, lungs, or
brain. Liver abscess is the
most common complication.
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Abdominal perforations and
peritonitis are rare
complications. Up to 5%
develop liver abscess.
Leber, in Murray 2007
Does the illness require short
term hospitalization (< week)?
Intestinal invasion can lead to
lesions, ulcers.
Leber in Murray 2007
Does the illness require
physician intervention?
[All populations]
Clinical symptoms are
dysentery, colitis or rarely
ameboma).
Fulminant colitis occurs
most often in children who
present with diffuse
abdominal pain, profuse
bloody diarrhea, and fever.
Leber, in Murray, 2007
Marshall, 1997
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Most human infections (90%)
are asymptomatic,
symptomatic non-invasive
strains cause gastrointestinal
symptoms such as cramping
and increased frequency of
bowel movements,
constipation may alternate
with diarrhea, invasive strains
may cause ameobic dysentery.
Heymann, 2005
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
41
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EPA-OGWDW CCL 3 Microbes: EPA 815-R-08-007
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United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Leber, A. and S. Novak-weekley. 2007 Intestinal and Urogenital Amebae, Flagellates, and
Ciliates. In Murray, P., E. Baron, J. Jorgensen, M. Landry, and M. Pfaller (ed.) The Manual of
Clinical Microbiology, 9th. edition, American Society for Microbiology, Washington, DC. Vol.
2: pp. 2097-2099.
Marshall,M, D Naumovitz, Y Ortega and C Sterling. 1997. Clinial Microbiology Reviews, Jan.
1997, p 73.
42
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EPA-OGWDW
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Enterovirus Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the
U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
Yes. Switzerland and others.
N/A
CDC, 2006; CDC, 2004;
Craun et al., 2003
Hafliger et al., 2000
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes
N/A
Mack et al., 1972;
Lieberman, et al. 2002;
Keswick et al., 1984
Borchardt et al., 2003
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
[C] Aseptic meningitis and
neonatal sepsis are the most
common complications.
EVs are the most common
cause of meningitis in the
Heymann, 2005
Romero, in Murray 2007
43
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Data Element
Scoring Data
Reference
term hospitalization (>
week)?
US, over 80% of all viral
meningitides (estimated
30,000 to 50,000
hospitalizations for Nonpolio
EV each year (principally
echo and coxsackie).
Enterovirus causes
myocarditis, viral
meningitis, encephalitis and
meningioencephalitis.
Khetsuriani et al, 2002;
Kim et al 2001; Khetsuriani
2003
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Diabetes has been associated
with enterovirus infection.
Heymann, 2005
Does the illness require
short term hospitalization (<
week)?
[G] Hospitalization may be
required for severe
manifestations of disease.
Approximately 20-30% of
meningitis outbreak cases in
young adults require
hospitalization.
During the Summer and Fall,
responsible for 50 - 60% of
hospital admissions for
evaluation of febrile illnesses
for infants and children
Sawyer, 2002
Romero, in Murray 2007
Does the illness require
physician intervention?
Children with acute
pharyngitis may be taken to a
physician to differentiate
between streptococcal and
viral sore throat. Upper
respiratory illness lasts 4-6
days, lower respiratory illness
lasts 5-7 days, and meningitis
lasts 7-10 days.
Romero, in Murray 2007
Heymann, 2005
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
[E, P, CD] Most cases are
asymptomatic. Most
common symptoms are
acute nonspecific febrile
illness.
44
Romero, in Murray 2007
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Data Element
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
Reference
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Borchardt, M. A., P. D. Bertz, S. K. Spencer, and D. A. Battigelli. 2003. Incidence of enteric
viruses in groundwater from household wells in Wisconsin. App. Environ. Microbiol.
69(2): 1172-1180.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1997-1998. MMWR Surveillance Summaries, 55(SS12); 31-65.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Hafliger D., P.Hubner and J. Luthy. 2000. Outbreak of viral gastroenteritis due to sewage-
contaminated drinking water, Int. J. Food Microbiol., 54(1-2)123 - 126.
Khetsuriani N., R. Holman, and L. Anderson. 2002. Burden of Encephalitis-Associated
Hospitalizations in the United States, 1988-1997. CID July 15, 2005:35. Page 175.
Khetsuriani, N. E.S. Quiroz, R.C. Holman and LJ. Anderson. 2003. Viral meningitis-associated
hospitalizations in the United States, 1988-1999. Neuroepidemiology, 22(6):345-352.
Kim, K., G. Hufnagel, N. Chapman and S. Tracy. 2001. The group B coxsackieviruses and
myocarditis Reviews in Medical Virology. 11:355.
Keswick, B, C. Gerba, H DuPont, and J Rose. 1984. Detection of Enteric Viruses in Treated
Drinking Water. App. And Env. Microbiology, June 1984, pp 1290 - 1294.
Lieberman, RJ, LC Shadix, BS Newport, CP Frebis, MWN Moyer, RS Safferman, RE Stetler, D
Lye, GS Fout and D Dahling. 2002. "Microbial monitoring of vulnerable public ground water
supplies." AWWA Research Foundation and AWWA, 142.
Mack, WN, L Yue-Shoung, and DB Coohon. 1972 "Isolation of poliomyelitis virus from a
contaminated well." Health Services Report, 87(3):271-274.
45
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Romero, J. 2007. Enteroviruses and Parechoviruses. In Murray, P., E. Baron, J. Jorgensen, M.
Landry, and M. Pfaller (ed.) The Manual of Clinical Microbiology, 9th. edition, American
Society for Microbiology, Washington, DC. Vol. 2: p. 1394.
Sawyer, M. H. 2002. Enterovirus infections: diagnosis and treatment. Seminars in Pediatric
Infectious Diseases 13(l):40-47.
46
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EPA815-R-08-007
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Escherichia coli (O157) Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs
in the U.S. since CDC
surveillance initiated in
1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
Yes
4 Community and 4 Non-
community
N/A
N/A
N/A
N/A
Craun, G., et al., 2003
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes, as a result of animal fecal
contamination.
N/A
Bopp et al., 2003
Kramer et al., 1996
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
No.
Approximately 60 deaths per
73,000 cases per year (nearly
> 1/1,000) are reported due to
E. coli STEC (O157). A case
fatality rate of 0.5 has been
reported for outbreaks-related
cases caused by E. coli
O157:H7.
Nataro, in Murray 2007
Rangel et al., 2005
47
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Data Element
Scoring Data
Reference
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?
[C, E] Patients at extremes
of age have an increased risk
for infection and associated
complications.
Children under 5 are most
frequently diagnosed with
infection and are at greatest
risk of developing HUS.
The elderly also appear to
be a increased risk of
complications.
HUS develops in 10% of
patients under the age of 10.
Chinyu 1995
Heymann, 2005
Nataro and Kaper, 1998
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
25% of HUS survivors
develop long term renal
sequelae.
3.2% of children with diarrhea
plus HUS develop diabetes.
Adults have a greater
likelihood of hypertension and
reduced renal function.
Garg et al, 2003
Suri et al., 2005
Garg et al, 2005
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
[G, P, CD] Fluid
replacement is the
cornerstone of treatment for
EHEC diarrhea; some
clinicians choose to
hospitalize all patients with
E. coli 0157:H7 for
hydratrion to prevent HUS.
Heymann, 2005
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
Can present as mild non-
bloody diarrhea.
48
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Data Element
impact on daily activities?
Scoring Data
Reference
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Bopp, D.J., B.D. Sauders, A.L. Waring, J. Ackelsberg, N. Dumas, E. Braun-Howland, D.
Dziewulski, BJ. Wallace, M. Kelly, T. Halse, K. Aruda Musser, P.P. Smith, D.L. Morse, and
RJ. Limberger. 2003. Detection, Isolation, and Molecular Subtyping of Escherichia coli
O157:H7 and Campylobacter jejuni Associated with a Large Waterborne Outbreak. Journal of
Clinical Microbiology. 41(1): 174-180.
Chinyu S, and L J Brandt. Escherichia coli: H7 Infection in Humans. 1995. Annals of Internal
Medicine: Vol 123, Issue 9, pp 698-707.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1997-1998. MMWR Surveillance Summaries, 55(SS12); 31-65.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Garg, A X, L Moist, D Matsel, H R Thiessen-Philbrook, R B Haynes, R S Suri, M Salvadori, J
Ray, and W F Clark. 2005. Risk of hypertension and reduced kidney function after acute
gastroenteritis from bacteria-contaminated drinking water. CMAJ August 2, 2005; 173 (3).
Garg, A X, R S Suri, N Barrowman, F Rehman, D Matsell, M P Rosas- Arellano, M Salvadori, R
B Haynes, and W F Clark. 2003. Long-term Renal Prognosis of Diarrhea- Associated Hemolytic
Uremic Syndrome. JAMA. September 10, 2003-Vol. 290. No. 10 pp 1360 -1370.
Heymann (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Kramer, M. H., B. L. Herwaldt, G. F. Craun, R. L. Calderon, and D. D. Juranek. 1996.
Surveillance for waterborne-disease outbreaks - United States, 1993-1994. MMWR 45(SS-): 1-
33.
Nataro, J., C. Bopp, P. Fields, J. Kaper and N. Strockbine. 2007. Escherichia, Shigella and
Salmonella. In Murray, P., E. Baron, J. Jorgensen, M. Landry, and M. Pfaller (ed.) The Manual
of Clinical Microbiology, 9th. edition, American Society for Microbiology, Washington, DC.
Vol. l:pp670-672.
Nataro, J. P. and J. B. Kaper. 1998. Diarrheagenic Escherichia coli. Clin. Microbiol. Rev.
Rangel, J. M., P. H. Sparling, C. Crowe, P. M. Griffin, and D. L. Swerdlow. 2005. Epidemiology
of Escherichia coli O157:H7 outbreaks, United States, 1982-2002. Emerg. Infect. Dis.
49
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11(4):603-609.
Suri, RS, WF Clark N Barrowman, J L Mahon, HR Thiessen-Philbrook, M P Rosas-Arellano, K
Zarnke, J S Garland, and A X Garg. 2005. Diabetes during diarrhea-associated hemolytic
uremic syndrome: a systematic review and meta-analysis. Diabetes Care, 2005 October, 28(10);
2556-62.
50
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Exophialajeanselmei Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
No
Yes
CDC, 2004; CDC; 2006;
Craun et al., 2003
Nucci et al., 2002
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes
N/A
West, 1986
Nucci etal., 2001
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
Does the illness result in long
No
Infections increase in severity
in patients with impaired
immunity and metabolic
diseases such as diabetes
No
De Hoog, in Murray 2007
51
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Data Element
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
No
[All populations] A chronic
spreading mycosis.
The frequency of infection is
low, yet potential severe
outcome and high degrees of
resistence to antifungal
drugs requires medical
attention.
Reference
Heymann, 2005.
De Hoog, in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Heymann (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Nucci, M. T. Akiti, G. Barreiros, F. Silveira, S. G. Revankar, D. A. Sutton, and T. F. Patterson.
2001. Nosocomial fungemia due to Exophiala jeanselmei \^. jeanselmei and a Rhinocladiella
species: newly described causes of bloodstream infection. J. Clin. Microbiol. 39(2):514-518.
Nucci, M. T., T. Akiti, G. Barreiros, F. Silveira, S. G. Revankar, B. L. Wickes, D. A. Sutton, and
T. F. Patterson. 2002. Nosocomial outbreak of Exophiala jeanselmei fungemia associated with
contamination of hospital water. Clin. Infect. Dis. 34:1475-1480.
52
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De Hoog, G. and R. Vitale. 2007. Bipolaris, Exophiala, Scedosporium, Sporothrix, and Other
Dematiaceous Fungi. In Murray, P., E. Baron, J. Jorgensen, M. Landry, and M. Pfaller (ed.)
The Manual of Clinical Microbiology, 9th. edition, American Society for Microbiology,
Washington, DC. Vol. 2: pp 1908 and 1918.
West, P. R. 1986. Isolation rates and characterization of fungi in drinking water distribution
systems. Proceedings of the Water Quality Technology Conference, American Water Works
Association, Denver, CO.
53
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Fusarium solani Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
No
Yes
Houston, TX
CDC, 2004; CDC 2006
and Craun 2003
Annaissie et al., 2001
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
N/A
N/A
Nagy and Olson, 1982
Annaissie et al., 2001
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
Mortality associated with
cutaneous Fusarium infection is
high in immunocompromised
patients but it is very low for
immunocompetent hosts.
Most severe disease occurs in
severely immunocompromised.
Fusarium has been associated
with pneumonia and
disseminated infections.
Nucci and Annaissie, 2002
Fridkin and Jarvis, 1996;
Annaissie et al., 2001
Verweij and Brandt, in
Murray 2007
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Data Element
Scoring Data
Reference
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require
short term hospitalization (<
week)?
[G, C, P, E, CD] Can cause
infections that may require
hospitalization, particularly in
immunocompromised patients
(endophtalmitis, central
nervous system infections,
endocarditis)
Dignani and Anaissie,
2004
Does the illness require
physician intervention?
Treatment and/or removal of the
foreign body is usually required
as well as antifungal therapy.
In inmunocompentent patients
manifestations include keratitis,
localized skin lesions,
onychomycosis, and occasionally
cellulitis and peritonitis.
Dignani and Anaissie, 2004
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Anaissie, E.J., R.T. Kuchar, J.H. Rex, A. Francesconi, M. Kasai, F-M.C. Muller, M. Lozano-
Chiu, R.C. Summerbell, M.C. Dignani, SJ. Chanock, and T.J. Walsh. 2001. Fusariosis
Associated with Pathogenic Fusarium Species Colonization of a Hospital Water System: A New
Paradigm for the Epidemiology of Opportunistic Mold Infections. Clin. Infect. Dis., 33: 1871-
1878.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
55
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PCCL to CCL Process February 2008 - DRAFT
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Dignani, M. andE. Anaissie. 2004. Human Fusariosis. Clin. Microbiol. Infect. Suppl. 1: 67-75.
Fridkin, S. and W. Jarvis. 1996. Epidemiology of Nosocomial Fungal Infections. Clin.
Microbiol. Rev. 9(4): 499-511.
Nagy L., and Olson B. 1982. The occurrence of filamentous fungi in drinking water distribution
systems. Can J Microbiol. 1982 Jun; 28(6):667-71
Nucci, M. and E. Anaissie. 2002. Cutaneous infection by Fusarium species in health and
immunocompromised hosts: implications for diagnosis and management. Clin. Infect. Dis.
35:909-920.
Verweij, P. and M. Brandt. 2007. Aspergillus, Fusarium, and Other Opportunistic Moniliaceous
Fungi. In Murray, P. R., E. J. Baron, J. H. Jorgensen, M. L. Landry and M. A. Pfaller (ed.)
Manual of Clinical Microbiology, 9th. Edition, American Society for Microbiology,
Washington, DC (Vol. 2). pp: 1818-1821.
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Helicobacterpylori Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
No
Yes
CDC, 2004; CDC, 2006 and
Craun, 2003
Klein and Graham, 1991
Hulten et al., 1996
Rolle-Kampczyk, 2004.
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
N/A
N/A
Hegarty and Baker, 1999
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
[G, E] 6500 deaths per year.
1.2 Million acute cases per
year (>1/1,000 deaths).
46% of deaths occur before
age of 64.
40 - 50% infection rates in
the elderly. More likely to
suffer from gastric ulcer ,
gastric adenocarcinomass and
MALT.
CDC, 1997
Stratton et al, 2000
Fox, in Murray 2007.
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Data Element
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
Main cause for peptic ulcers
and a major risk factor for
gastric cancer.
[C, P, CD] Many patients
have recurrent abdominal
symptoms 16% develop
duodenal ulcers. NIH (1994)
recommends diagnosis and
antimicrobial treatment for
anyone with peptic ulcers.
No. Infection persists lifelong
without treatment.
Reference
Fox, in Murray 2007
Fox, in Murray, 2007.
Fox, in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 1997. Knowledge About Causes of Peptic Ulcer Disease — United States, March-April
1997, October 24, 1997 / 46(42);985-987
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Fox, G. and F. Megraud. 2007. Helicobacter. In Murray, P., E. Baron, J. Jorgensen, M. Landry,
and M. Pfaller (ed.) The Manual of Clinical Microbiology, 9th. edition, American Society for
Microbiology, Washington, DC. Vol. 1: p.950.
Hegarty, J. P. and K. H. Baker. 1999. Occcurrence of Helicobacter pylori in surface water in the
58
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United States. J. Appl Microbiol. 87:697-701.
Hulten, K., S. W. Han, H. Enroth, P. D. Klein, A. R. Opekun, R. H. Oilman D. G. Evans, L.
Engstrand, D. Y. Graham, and F. A. K. El-Zaatari. 1996. Helicobacterpylori in the drinking
water in Peru. Gastroenterology 110:1031-1035.
Klein, P. D, D. Y. Graham, Gaillour, A, Opekun, A.R and Smith, E.G. 1991. Water source as risk
factor for Helicobacter pylori infection in Peruvian children. Lancet 337(8756):1503-1506.
Rolle-Kampczyk, U.E., GJ. Fritz, U. Diez, I. Lehman, M. Richter, and O. Herbarth. 2004. Well
water - one source for Helicobacter pylori colonization. . International Journal of Hygiene and
Environmental Health. 207:363-368.
Stratton, K., J. Durch, and R. Lawrence (Editors). 2000. Vaccines for the 21st Century.
National Academy of Sciences, National Academy of Press, pp. 181-187.
59
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Hepatitis A Virus Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs
in the U.S. since CDC
surveillance initiated in
1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
Yes
10 Community and 10
Noncommunity outbreaks
N/A
N/A
N/A
N/A
Craun et al., 2003
Occurrence
Detected in drinking water in
the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
N/A
Abbaszadegan et al., 2003
Borchardt et al., 2004
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
Reported case fatality is
normally low, 0.1%-0.3%; it
can reach 1.8% for adults over
50
[E] Fulminant hepatitis may
develop. Disease severity
shows a general increase
with age.
Heymann, 2005
Anderson, in Murray 2007
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Data Element
hospitalization (> week)?
Does the illness result in
long term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
[G, C, P, CD] Commonly
begins with "flu-like"
symptoms. May develop
jaundice. Physician office
visit is common for
diagnosis and/or
vaccination.
Reference
Anderson, in Murray 2007.
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Abbaszadegan, M., M. LeChevallier, and C. P. Gerba, 2003. Occurrence of viruses in U. S.
groundwaters. JAWWA 95:107-120.
Anderson, D. 2007 . Hepatitis A and E Viruses. In Murray, P., E. Baron, J. Jorgensen, M.
Landry, and M. Pfaller (ed.) The Manual of Clinical Microbiology, 9th. edition, American
Society for Microbiology, Washington, DC. Vol. 2: p. 1428 - 1429.
Borchardt, M. A., N.L. Haas and R.L. Hunt. 2004. Vulnerability of drinking-water wells in La
Crosse, Wisconsin to enteric-virus contamination from surface water contributions. Appl.
Environ. Microbiol. 10:5937-5946.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
61
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United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
62
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EPA815-R-08-007
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Hepatitis E Virus Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the
U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
Yes, waterborne outbreaks
have occurred in Asia and
Africa
California camping.
CDC, 2004; CDC, 2006;
Craun et al., 2003
Guthmann et al., 2006
Panda et al., 2006
Tsang et al., 2000
Occurrence
Detected in drinking water in
the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
No
No
Yes, India.
Jothikumar et al., 2000
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
[P] May progress to
fulminant disease in
pregnant women when
infection occurs during the
third trimester. High
mortality (for fetus) when
infection occurs during
pregnancy.
The case-fatality rate is
similar to that of hepatitis A
Anderson, in Murray 2007
Heymann, 2005
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Data Element
Scoring Data
Reference
except in pregnant women,
where it may reach 20%
among those infected during
the third trimester of
pregnancy.
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?
[E] Fulminant hepatitis may
develop. Disease severity
shows a general increase
with age.
Anderson, in Murray 2007
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
[G, C] Commonly begins
with "flu-like" symptoms.
May develop jaundice.
Physician office visit is
common for diagnosis
and/or vaccination.
Anderson, in Murray et al.,
2007
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Anderson, D. 2007 . Hepatitis A and E Viruses. In Murray, P., E. Baron, J. Jorgensen, M.
Landry, and M. Pfaller (ed.) The Manual of Clinical Microbiology, 9th. edition, American
Society for Microbiology, Washington, DC. Vol. 2: p. 1428 - 1429.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
64
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United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Guthmann, J-P., H. Klovstad, D. Boccia, N. Hamid, L. Pinoges, J. Nizou, M. Tatay, F. Diaz, A.
Moren, R. F. Grais, I. Ciglenecki, E. Nicand, and P. J. Guerin. 2006. A large outbreak of
hepatitis E among a displaced population in Darfur, Sudan, 2004: the role of water treatment
methods. Clin. Infect. Dis. 42:1685-1691.
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Jothikumar N., R. Paulmurugan, P. Padmanabhan, R. Sundari, S. Kamatchiammal, and K. Rao.
2000. Duplex RT-PCR for simultaneous detection of hepatitis A and hepatitis E virus isolated
from drinking water samples. J Environ Monit. 2(6): 587-90
Panda, S., D. Thakral, and S. Rehman. 2006. Hepatitis E virus. Rev. Med. Virol. (in press).
Tsang, T., E. Denison, H. Williams, L. Venczel, M. Ginsberg, and D. Vugia. 2005
Acute Hepatitis E Infection Acquired in California. Clinical Infectious Diseases 30:618-9
65
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Isospora belli Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the
U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
Yes
Yes
CDC, 2004; CDC, 2006 and
Craun, 2003
Karanis, 2006
Occurrence
Detected in drinking water in
the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
No
No
No
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
66
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Data Element
Scoring Data
Reference
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Can cause serious and
sometimes fatal disease in
immunocompetant humans,
more severe in
immunocompromi sed
patients.
Lindsay, in Murray 2007
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
[C] Symptoms are more
severe in infants and
children.
Lindsay, in Murray 2007
Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?
[G] Symptoms include
diarrhea, steatorrhea,
headache, fever, malaise,
abdominal pain, vomiting,
dehydration, and weight
loss.
Lindsay, in Murray, 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Karanis, P. 2006 A review of an emerging waterborne medical important parasitic protozoan.
Jpn. JProtozool. Vol 39, No. 1 (2006)
Lindsay, D., S. Upton, and L. Weiss. 2007. Isospora, Cyclospora, and Sarcocystis. In Murray,
P., E. Baron, J. Jorgensen, M. Landry, and M. Pfaller (ed.). The Manual of Clinical
Microbiology, 9th. edition, American Society for Microbiology, Washington, DC Vol. 2. pp
2097-2099
67
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Legionella pneumophila Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs
in the U.S. since CDC
surveillance initiated in
1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
Yes
6 Community outbreaks
7 Community outbreaks
N/A
N/A
N/A
N/A
CDC, 2004
CDC, 2006
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes
N/A
AwwaRF, 2004
Lin et al, 1998
Maier et al., 2000
Maier et al., 2000
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Avg. 12% fatality rate; death
rates of 15% (general pop.) up
to 75% immunocompromised)
if untreated.
AwwaRF: Avg. 25% death
rate (between 20-40% during
an outbreak
CDC: 10 -15% death rate
Fatality rate has been as high
Edel stein, in Murray, 2007
CDC, 2005
AwwaRF, 2004
Heymann, 2005
68
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Data Element
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require
short term hospitalization (<
week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
as 39% in hospitalized cases;
it is generally higher in those
with compromised immunity.
[E, CD] Acute pneumonia
may progress to respiratory
collapse and death if
diagnosis and effective
antibiotic therapy are
delayed. The elderly and
individuals with chronic
diseases are at higher risk.
No
[G, C, P] Hospitalization is
required for treatment of
acute pneumonia.
Pontiac fever resolves without
treatment and has flu-like
symptoms.
Reference
Edelstein, in Murray, 2007
CDC, 2005
Edelstein, in Murray, 2007
Edelstein, in Murray 2007
Heymann, 2005
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
AwwaRF. S. Riffard, S. Springthorpe, L. Filion, S. Sutler, T. Brooks, R. Osicki, M. Lee, and D.
Abrial. 2004. Occurrence of Legionellain Groundwater. September 1, 2004. ISBN:
1843398818
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2005. Legionellosis: Legionnaires' Disease (LD) and Pontiac Fever. Disease Listing.
October 12, 2005. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/legionellosis_t.htm
69
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CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Edelstein, P. 2007. Legionella. In Murray, P., E. Baron, J. Jorgensen, M. Landry, and M.
Pfaller (ed.) The Manual of Clinical Microbiology, 9th. edition, American Society for
Microbiology, Washington, DC. Vol. 1: p 837.
Heymann. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Lin, Y. S., J. E. Stout, V. L. Yu, and R. D. Vidic. 1998. Disinfection of water distribution
systems for Legionella. Semin. Respir. Infect. 13:147-159.
Maier, R. M., I. L. Pepper, C. P. Gerba. 2000. Environmental Microbiology. Academic Press.
pp: 454-455, 539.
70
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Microsporidia Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
No
Yes
CDC, 2004; CDC; 2006;
Craun, 2003
Cotte, et al., 1999
Enriquez et al., 1998
Hutin et al., 1998
Occurrence
Detected in drinking water in
the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
No
Yes
N/A
Didier et al., 2004
Dowd et al., 1998
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
71
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Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Antimicrobial therapy
available for immunodeficient
patients.
[G, C, E, P, CD] Diarrhea
and weight loss lasting in up
to 2 - 3 weeks in
immunocompetent hosts.
Has been identified among
elderly persons with acute or
chronic diarrhea.
Weber, in Murray 2007
Weber, in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Cotte, L., M. Rabondonira, F. Chapuis, F. Bailly, F. Bissuel. C. Raynal. 1999. Waterborne
outbreak of intestinal microsporidiosis in persons with and without human immunodeficiency
virus infection. J. Infect. Dis. 180:2003-2008.
72
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EPA-OGWDW CCL 3 Microbes: EPA 815-R-08-007
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Didier, E., M. Stovall, L. Green, P. Brindley, K. Sestak, and P. Didier. 2004. Vet. Parasitol.
126:145-166.
Dowd, S., C. Gerba, I. Pepper. 1998. Confirmation of the human-pathogenic microsporidia
Enterocytozoon bieneusi, Encephalitozoon intestinalis, and Vittaforma corneae in water. Appl.
Environ. Microbiol. 64(9):3332-3335.
Enriquez, F., D. Taren, A. Cruz-Lopez, M. Muramoto, J. Falling, P. Cruz. 1998. Prevalence of
intestinal encephalitozoonosis in Mexico. Clin. Infect. Dis. 26:1227-1229.
Hutin, Y., M. Sombardier, O. Ligoury, C. Sarfati, F. Derouin, J. Modai, J. Molina. 1998. Risk
factors for intestinal micorspooridiosis in patients with human immunodeficiency virus
infection.: a case control study. J. Infect. Dis. 178:904-907.
Weber R., A. Mathis and P. Deplazes. 2007. Microsporidia. In Murray, P., E. Baron, J.
Jorgensen, M. Pfaller, and R.Yolken (ed.) The Manual of Clinical Microbiology, 9th editic
American Society for Microbiology, Washington, DC Vol. 2; pp 2133-2135.
73
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EPA815-R-08-007
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Mycobacterium avium Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
Yes. Not listed by CDC
MMWR data however, data
linking patient, outbreak
and drinking water.
No
No
Yes
CDC, 2004; CDC, 2006 and
Craun, 2003
Tobin-D'Angelo et al., 2004
Glover etal., 1994
Aronson et al., 1999
vonReyn etal., 1994
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes
N/A
Glover et al., 1994
Covert et al., 1999
Falkinham et al., 2001
Covert etal., 1999
Falkinham et al., 2004
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
Disseminated MAC infections
are a major problem in HIV-
Infected individuals.
Heymann, 2005
74
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Data Element
Scoring Data
Reference
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
None reported
Does the illness require
short term hospitalization (<
week)?
[CD] Tuberculosis-like
upper lobe fibrocavitary
disease occurs typically in
men 45 - 60 who have
preexisiting lung disease.
Pfyffer, in Murray 2007
Does the illness require
physician intervention?
[G]Symptoms of infection
include pulmonary disease,
lymphadenitis, post-
traumatic wound infection.
Diagnosis of disease and
treatment requires
physician intervention.
Pfyffer, in Murray 2007
Heymann, 2005
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Aronson, T., A. Holtzman, N. Glover, M. Boian, S. Froman, O. G. W. Berlin, H. Hill, and G.
Stelma, Jr. 1999. Comparison of large restriction fragments of Mycobacterium avium isolates
recovered from AIDS and non-AIDS patients with those of isolates from potable water. J. Clin.
Microbiol. 37:1008-1012.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
75
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Health Association, Washington, DC.
Covert, T. C., M. R. Rodgers, A. L. Reyes, and G. N. Stelma, Jr. 1999. Occurrence of
nontuberculous mycobacteria in environmental samples. Appl. Environ. Microbiol. 65:2492-
2496.
Falkinham, J. O., Ill, C. D. Norton, and M. W. LeChevallier. 2001. Factors influencing numbers
of Mycobacterium avium, Mycobacterium intracellulare, and other mycobacteria in drinking
water distribution systems. Appl. Environ. Microbiol. 67:1225-1231.
Falkinham, J. O., G. Nichols, J. Bartram, A. Dufour, and F. Portaels. 2004. Natural ecology and
survival in water of mycobacteria of potential public health importance. . In Pedley, S., J.
Bartram, G. Rees, A. Dufour, and J. A. Cotruvo (Eds.) Pathogenic mycobacteria in water: a
guide to public health consequences, monitoring and management. IWA Publishing, London,
UK.
Glover, N. , A. Holtzman, T. Aronson, S. Froman, O. G. W. Berlin, P. Dominguez, K. A.
Kunkel, G. Overturf, G. Stelma, Jr., C. Smith, and M. Yakrus. The isolation and identification of
Mycobacterium avium complex (MAC) recovered from Los Angeles potable water, a possible
source of infection in AIDS patients. Int. J. Environ. Health Res. 4:63-72.
Pfyffer, G. 2007 . Mycobacterium: General Characterisitis, Laboratory Detection, and Staining
Procedures. In Murray, P., E. Baron, J. Jorgensen, M. Landry, and M. Pfaller (ed.) The Manual
of Clinical Microbiology, 9th. edition, American Society for Microbiology, Washington, DC.
Vol. l:pp547-548.
Tobin-D'Angelo, M. J., M. A. Blass, C. del Rio, J. S. Halvosa, H. M. Blumberg, and C. R.
Horsburgh, Jr. 2004. Hospital water as a source of Mycobacterium avium complex isolates in
respiratory specimens. J. Infect. Dis. 189:98-104.
von Reyn, C. F., J. N. Maslow, T. W. Barber, J. O. Falkinham, III, and R. D. Arbeit. 1994.
Persistent colonization of potable water as a source of Mycobacterium avium infection in AIDS.
Lancet 343:1137-1141.
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Naegleria fowleri Scoring Data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
Yes
1 Community outbreak
N/A
N/A
N/A
CDC, 2004; CDC, 2006;
Craun et al., 2003
CDC, 2004;
Marciano-Cabral et al., 2003
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Storage in Arizona.
Sampled pre-treatment
multiple-well study in
Arizona.
Yes
N/A
Gerba, 2007
Schuster and Visvesvara,
2004
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
[All populations] Recovery
from primary amoebic
meningoencephalitis is rare.
Acute fulminating disease.
Only a few patients have
survived.
Heymann, 2007
Visvesvara, in Murray, 2007
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Data Element
illness necessitating long term
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
No.
All cases are hospitalized for
diagnosis and treatment.
N/A
N/A
N/A
Reference
Visvesvara, in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Gerba, C., B. Blair, P. Sarkar, and K. Bright. 2007. Occurrence and Control of Naegleria
fowled in Well Water and Chlorine Resistance. Proceedings, Water Quality Technology
Conference, American Water Works Association, November 5-8,2007.
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Marciano-Cabral, F., R. MacLean, A. Mensah, and L. LaPat-Polasko. 2003. Identification of
Naegleria fowleri in domestic water source by nested PCR. Appl. Environ. Microbiol.
(69)10:5864-5869.
Schuster, F. L. and G. S. Visvesvara. 2004. Free-living amoebae as opportunistic and non-
opportunistic pathogens of humans and animals. Int. J. Parasitol. 34:1001-1027.
78
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Visvesvara, G. 2007. Pathogenic and Opportunistic Free-Living Amebae. In Murray, P., E.
Baron, J., Jorgensen, M. Pfaller, and R. Yolken (ed.) The Manual of Clinical Microbiology, 9
edition, American Society for Microbiology, Washington, DC Vol. 2; pp 2082-2086.
,th
79
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Plesiomonas shigelloides Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
Yes
1 Noncommunity outbreak
N/A
N/A
N/A
CDC, 2004; CDC, 2006
Craun, G., et al., 2003
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes
N/A
CDC,1998
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
No
No
80
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Data Element
Scoring Data
Reference
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
No
Does the illness require short
term hospitalization (< week)?
Hospitalization may be
required for severe infections
and/or underlying diseases.
Abbott 2003
Does the illness require
physician intervention?
[C, E] Physician office visit
may be required for
diagnosis and treatment of
dysenteric form of the
disease in children or the
elderly. Bacteremia more
common with advanced age.
Abbott, in Murray 2007
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
[G] Diarrhea may persist up
to two weeks.
Abbott, in Murray 2007
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Plesiomonas is associated
with travelers' diarrhea or a
history of seafood
consumption, most infections
are self-limiting.
Abbott, in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Abbott, S. L. 2007. Klebsiella, Enterobacter, Citrobacter, Serratia, Plesiomonas, and other
Enterobacteriaceae. In Murray, P. R., E. J. Baron, J. H. Jorgensen, M. A. Pfaller, and R. H
Yolken (ed.) The Manual of Clinical Microbiology, 9th edition, American Society for
Microbiology, Washington, DC Vol. 2.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
CDC. 1998. Plesiomonas shigelloides and Salmonella serotype Hartford infections associated
with a contaminated water supply - Livingston County, New York, 1996. MMWR 47(19): 3 94-
396.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
81
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EPA-OGWDW CCL 3 Microbes: EPA 815-R-08-007
PCCL to CCL Process February 2008 - DRAFT
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Holmberg, S. and J. Farmer. 1984. Aeromonas hydrophila and Plesiomonas shigelloides as
causes of intestinal infections. Rev. Infect. Dis. 6:633-639.
Holmberg, S., K. Wachsmith, F. Hickman-Brenner, P. Blake, and J. Farmer. 1986. Plesiomonas
enteric infections in the United States. Ann. Intern. Med. 105:690-694.
82
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Rotavirus Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
Yes
1 Community
N/A
N/A
N/A
CDC, 2004; CDC, 2006
Craun et al., 2003
Occurrence
Detected in drinking water in
the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
No
Yes
N/A
Abbaszadegan et al., 2003
Gerba et al., 1996
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
No
For children under 5 years of
age: Estimated 37 deaths in
60,000 hospitalized cases per
year in U.S. (1/1621
hospitalizations)
[C] Rotavirus infects all
children; causes severe
gastroenteritis in infants.
Significant numbers of
Fischer et al., 2007
83
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Data Element
other severe manifestations
of illness necessitating long
term hospitalization (>
week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in
mild symptoms with
minimal or no impact on
daily activities?
Scoring Data
physician visits and
hospitalizations and high
medical and societal costs.
A sporadic, seasonal, often
severe gastroenteritis of
infants and young children,
characterized by vomiting,
fever and watery diarrhea.
Rotaviral enteritis is
occasionally associated with
severe dehydration and
death in young children. In
developing countries, an
estimated 600,000-870,000
diarrheal deaths each year.
No
No
No
No
[G,E,P,CD]
Self-limiting acute watery
diarrhea, vomiting, fever.
Reference
Farkas, in Murray 2007
Heymann, 2005
Heymann, 2000
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Abbaszadegan, M., M. LeChevallier, and C. P. Gerba. 2003. Occurrence of viruses in U. S.
groundwaters JAWWA 95:107-120.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
84
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PCCL to CCL Process February 2008 - DRAFT
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Farkas, T and X. Jiang. 2007. Rotaviruses, Caliciviruses, Astroviruses, Enteric Adenoviruses,
and Other Diarrheic Viruses. In Murray, P. R., E. J. Baron, J. H. Jorgensen, M. A. Pfaller, and
R. H Yolken (ed.) The Manual of Clinical Microbiology, 9th edition, American Society for
Microbiology, Washington, DC Vol. 2; pp!454-1457.
Fischer, T K , C Viboud, U Parashar, M Malek, C Steiner, R Glass, and Lone Simonsen. 2007.
Hospitalizations and deaths from diarrhea and rotavirus among children < 5 years of age in the
United States, 1993-2003. Journal of Infectious Diseases 195:1117.
Gerba, C. P., J. B. Rose, C. N. Haas, and K. D. Crabtree. 1996. Waterborne rotavirus: a risk
assessment. Wat. Res. 30:2929
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
85
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Salmonella enterica Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs
in the U.S. since CDC
surveillance initiated in
1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
Yes
11 Community outbreaks
and 2 Non-community
outbreaks
1 Non-community outbreak
N/A
N/A
N/A
N/A
Craun, G., et al., 2003
CDC, 2006
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes.
N/A
N/A
Angulo et al., 1997
CDC, 1998.
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Each year, 1 .4 M cases of
illness and 600 deaths are
caused by non-typhoidal
salmonellosis in the U.S.
Estimated 800 cases per year
of typhoid fever in the U.S.,
with fewer than 5 deaths/yr.;
>70% of U.S. cases related to
foreign travel.
Nataro, in Murray 2007
86
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Data Element
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require
short term hospitalization (<
week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
Non-typhoidal salmonellosis
usually causes intestinal
infection; can cause
extraintestinal infections in
rare cases (bacteremia, UTI,
osteomyelitis), especially in
immunocompromised persons.
None reported
[C] Extra-intestinal
infections highest in infants
and young children.
[E] Dehydration, especially
among infants or in the
elderly, may be severe.
Deaths are uncommon,
except in the young and old,
the debilitated and
immunosuppressed.
[G, P, CD] antibiotic and
rehydration may be
necessary.
Non-typhoidal Salmonella
usually cause intestinal
infection that often lasts 1
week or longer.
Reference
Nataro, in Murray 2007
Nataro, in Murray 2007
Heymann 2005, p 469.
Heymann, 2007
Nataro, in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Angulo, F., S. Tippen, D. Sharp, B. Payne, C. Collier, J. Hill, T. Barrett, R. Clark, E. Geldreich,
H. Donnell, Jr., D. Swerdlow. 1997. A community waterborne outbreak of salmonellosis and the
effectiveness of a boil water order. Am. J. Public Health 87(4):580-584.
87
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EPA-OGWDW CCL 3 Microbes: EPA 815-R-08-007
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CDC. 1998. Plesiomonas shigelloides and Salmonella serotype Hartford infections associated
with a contaminated water supply - Livingston County, New York, 1996. MMWR 47(19): 3 94-
396.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 1997-1998. MMWR Surveillance Summaries, 55(SS12); 31-65.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
CDC. 1998. Plesiomonas shigelloides and Salmonella serotype Hartford infections associated
with a contaminated water supply - Livingston County, New York, 1996. MMWR 47(19): 3 94-
396.
Heyman, D. (ed.). 2007. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Nataro, J., C. Bopp, P. Fields, J. Kaper, and N. Strockbine. 2007. Escherichia, Shigella, and
Salmonella. In Murray, P., E. Baron, J. Jorgensen, M. Landry, and M. Pfaller (ed.) The Manual
of Clinical Microbiology, 9th. edition, American Society for Microbiology, Washington, DC.
Vol. 1: pp. 680-687.
88
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Shigella sonnei Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs
in the U.S. since CDC
surveillance initiated in
1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
Yes
14 Community outbreaks
and 24 Noncommunity
outbreaks
N/A
N/A
N/A
N/A
Craun, 2003
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes
N/A
Craun, 2003
Black etal., 1978
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or
other severe manifestations
of illness necessitating long
In U.S. approximately
450,000 cases occur each year
with 70 deaths.
[C, E] S. dysentariae is
associated with more serious
symptoms than other species
with complications such as
toxic megacolon, hemolytic
uremic syndrome and
Nataro, in Murray 2007
Heymann, 2005
89
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Data Element
Scoring Data
Reference
term hospitalization (>
week)?
intestinal perforation. Cases
may be severe in infants and
the elderly and convulsions
may occur in young
children.
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Reiter syndrome
Heymann, 2005
Does the illness require short
term hospitalization (< week)?
Hospitalization is usually
required for intravenous
antibiotic therapy due to
bacteremia, which is
Heymann, 2005
uncommon.
Does the illness require
physician intervention?
[G] Most cases occur in
children under 10 years,
infants under 6 months
rarely infected, increased
severity in children and
elderly, high secondary case
rate in outbreaks, outbreaks
occur in daycare centers,
institutions, and refugee
camps. 20% of U.S. cases
result from international
travel, specific antibiotic
therapy available for
prolonged or severe cases,
multi-antibiotic resistance
occurs.
Heymann, 2005
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Acute diarrhea, fever, nausea,
vomiting, cramps and
tenesmus, stools contain blood
and mucus (dysentery),
usually self-limiting in 4-7
days without treatment.
Heymann, 2005
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
S. sonnet causes most of the
shigellosis cases in the U.S.,
cases may be asymptomatic or
mildly symptomatic, but they
are frequently acute.
90
Heymann, 2005
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EPA-OGWDW CCL 3 Microbes: EPA 815-R-08-007
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Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Black, R., G. Craun, and P. Blake. 1978. Epidemiology of common-source outbreaks of
shigellosis in the United States, 1961-1975. Am. J. Epidemiol. 108:47-52.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Heymann. (ed.). 2005. Control of communicable diseases manual. 18th edition. American Public
Health Association, Washington, DC.
Nataro, J. C Bopp, P Fields, J. Kaper and N. Strockbine. 2007. Escherichia, Shigella, and
Salmonella. In Murray, P., E.Baron, J. Jorgensen, M. Pfaller, and R.Yolken (ed.) The Manual
of Clinical Microbiology, 9th edition, American Society for Microbiology, Washington, DC.
Vol. l.pp. 670, 677-678.
91
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Toxoplasma gondii Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs in
the U.S. since CDC
surveillance initiated in 1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the
U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
No
No
No
Yes
Canada
Brazil
N/A
CDC, 2004; CDC; 2006;
Craun, 2003
Bowie et al., 1997
de Moura, 2006
Occurrence
Detected in drinking water in
the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
No
No
Yes.
Ground water in Poland.
Canada.
Sroka, 2006
Isaac-Renton, 1998
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
[P] Congenital infection of
neonates severe.
Infection during early
pregnancy may lead to fetal
infection with death of the
fetus or other severe
manifestations. Later in
Wilson, in Murray 2007.
Heymann, 2005
92
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Data Element
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
pregnancy, maternal
infection results in mild or
subclinical fetal disease.
Immunocompromised hosts
may experience CNS,
pneumonitis, and myocarditis.
Treatment is indicated only
for pregnant women, infants
and immunocompromised
hosts.
[G all populations except
PW] Infection is generally
asymptomatic however 10 -
20% of patients with acute
infection may develop
cervical lymphadenopathy
and/or flu-like symptoms.
Reference
Wilson, in Murray 2007.
Wilson, in Murray 2007
Wilson, in Murray 2007
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
Bowie, W., S. King, D. Werker, J. Isaac-Renton, A. Bell, S. Eng, and S. Marion. 1997. Outbreak
of toxoplasmosis associated with municipal drinking water. Lancet 350:173-177.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
93
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United States, 2003— 2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
L. De Moura, L. Bahia-Oliveira, M. Wada, J. Jones, S. Tuboi, E. Carmo, W. Ramalho, N.
Camargo, R. Trevisan, R. Graca, A. da Silva, I. Moura, J. Dubey, and D. Garrett. Waterborne
toxoplasmosis, Brazil, from field to gene. 2006. Emerging Infectious Diseases, Vol. 12, No. 2,
February 2006.
Isaac-Renton, J., W. Bowie, A. King, G. Irwin, C. Ong, C. Fung, M. Shokeir and J. Dubey.
1998. Detection of Toxoplasma gondii Oocysts in Drinking Water. App and Env
Microbiology. P 2278-2280.
Sroka J., A. Wojcik-Fatla, J. Dutkiewicz. 2006. Occurrence of Toxoplasma Gondii in Water
from Wells Located on Farms. Ann Agric Environm Med, 13, 169-175.
Wilson, M., J. Jones and J. McAuley. 2007. Toxoplasma. In Murray, P., E. Baron, J.
Jorgensen, M. Landry, and M. Pfaller (ed.) The Manual of Clinical Microbiology, 9th. edition,
American Society for Microbiology, Washington, DC. Vol. 2: p.2070.
94
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Vibrio cholerae Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs
in the U.S. since CDC
surveillance initiated in
1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
Yes
1 Community and 1 Non-
community outbreak
1 Community outbreak
N/A
N/A
N/A
N/A
Craun, 2003
CDC, 2004
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes (outbreak data)
Yes
N/A
Rhodes et al., 1986
Kaperetal., 1982
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
No. V. cholerae Non-Ol: third
most commonly isolated in
U.S. - Septicemia case fatality
rate from 47-65%.
No. V. cholerae Ol:
Extremely rare cases causes
severe extraintestinal
infection. If untreated, V.
cholerae Ol infection causes
Abbott, in Murray 2007
Abbott, in Murray 2007
95
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Data Element
Scoring Data
Reference
illness necessitating long term
hospitalization (> week)?
severe dehydration which
leads to hypovolemic shock,
acidosis, circulatory collapse,
and death. Unlike Ol strains,
non-Ol isolates are commonly
associated with
extrainstestinal infections
such a septicemia.
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
No
Does the illness require short
term hospitalization (< week)?
No. In severe dehydrated
cases (cholera gravis), death
may occur within a few hours,
and the case-fatality rate may
exceed 50%. With proper and
timely rehydration, this can be
less than 1%.
Heymann, 2007
Does the illness require
physician intervention?
[All populations] In most
cases infection is
asymptomatic or causes
mild diarrhea.
Treatment consists of fluid
replacement by oral
rehydration therapy and/or
intravenous fluids.
Heymann, 2007
Abbott, in Murray 2007
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
96
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Abbott, S., J. Janda, J. Johnson, and J. Farmer. 2007. Vibrio and Related Organisms. In Murray,
P., E. Baron, J. Jorgensen, M. Pfaller, and R.Yolken (ed.) The Manual of Clinical Microbiology,
8th. edition, American Society for Microbiology, Washington, DC (2 volumes), pp: 723-733.
Kramer, M., B. Herwaldt, G. Craun, R. Calderon and D. Juranek. 1996. "Waterborne disease:
1993-1994." Morbidity and Mortality Weekly Report. 45(SS-l):l-33.
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
CDC, 2006. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2003—2004. MMWR Surveillance Summaries, 55(SS12); 31-58.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Kaper, J., H. Bradford, N. Roberts, and S. Falkow. 1982. Molecular epidemiology of Vibrio
cholerae in the U.S. Gulf Coast. J. Clin. Microbiol. 16(1):129-134.
Rhodes, J., H. Smith Jr., and J. Ogg. 1986. Isolation of Non-Ol Vibrio cholerae Serovars from
Surface Waters in Western Colorado. Appl. Environ. Microbiol. 51(6): 1216-1219.
97
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Yersinia enterocolitica Scoring Data
Bolded Text indicates scored data
Data Element
Scoring Data
Reference
Waterborne Disease Outbreaks
Has caused multiple (2 or
more) documented WBDOs
in the U.S. since CDC
surveillance initiated in
1973?
Has caused at least one
documented WBDO in the
U.S. since CDC surveillance
initiated in 1973?
Has caused documented
WBDOs at any time in the
U.S.?
Has caused WBDOs in
countries other than the U.S.?
Has never caused WBDOs in
any country, but has been
epidemiologically associated
with water related disease?
Yes
1 Noncommunity outbreak
1 Noncommunity outbreak
N/A
N/A
N/A
N/A
Craun, 2003
CDC, 2004
Occurrence
Detected in drinking water
in the U.S.?
Detected in source water in
the U.S.?
Not detected in the U.S.?
Yes
Yes
N/A
Highsmith, et al., 1977
Eden, et al., 1977
Meadows and Snudden, 1982
Health Effects
Does the organism cause
significant mortality (>
1/1,000 cases)?
Does the organism cause
pneumonia, meningitis,
hepatitis, encephalitis,
endocarditis, cancer, or other
severe manifestations of
illness necessitating long term
hospitalization (> week)?
No
No. An uncommon
complication of gastroenteritis
is septicemia for which the
elderly and
immunocompromised are at
higher risk, particularly those
with metabolic diseases
Wanger, in Murray 2007.
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Data Element
Does the illness result in long
term or permanent
dysfunction or disability, i.e.
sequelae?
Does the illness require short
term hospitalization (< week)?
Does the illness require
physician intervention?
Is the illness self-limiting
within 72 hours (without
requiring medical
intervention)?
Does the illness result in mild
symptoms with minimal or no
impact on daily activities?
Scoring Data
associated with iron overload
(hemochromatosis), cancer,
liver disease and steroid
therapy.
No. Uncommon sequelae
include: reactive arthritis,
inflammatory bowel disease,
autoimmune thyroid disorders.
No
No. The elderly are at greater
risk for septicemia.
[G, C other populations not
mentioned] Young children
most commonly develop
gastroenteritis and present
with fever, diarrhea, and
abdominal pain. Symptoms
typically resolve within 7
days.
Infection typically
manifested by acute febrile
diarrhea with abdominal
pain (especially in young
children). Diarrhea may be
absent in up to a third of Y.
enterocolitica infections.
Reference
Wanger, in Murray 2007
Wanger, in Murray 2007
Wanger, in Murray 2007
Heymann, 2005
Populations: G - General, C- Child, E-Elderly, P- Pregnant Women, CD-Chronic Disease
References
CDC, 2004. Surveillance for Waterborne-Disease Outbreaks Associated with Drinking Water —
United States, 2001—2002. MMWR Surveillance Summaries, 53(SS08); 23-45.
Craun, G., R. Calderon, and M. Craun. 2003. Waterborne Outbreaks in the United States, 1971-
2000, in Drinking Water Regulation and Health. F. Pontius (ed.) pp 45 - 60.
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Eden, K., M. Rosenberg, M. Stoopler, B. Wood, A. Highsmith, P Skaliy, J. Wells, J. Feeley.
Waterborne gastrointestinal illness at a ski resort. Isolation of Yersinia enterocolitica from
drinking water. Public Health Report 1977, May - June. 92(3): 245-50.
Heymann, D. (ed.). 2005. Control of Communicable Diseases Manual, 18th ed. American Public
Health Association, Washington, DC.
Highsmith, A., J. Feeley, P. Skaliy, J. Wells, and B. Wood. 1977. Isolation of Yersinia
enterocolitica from well water and growth in distilled water. Appl. Environ. Microbiol. 34:745-
750.
Meadows, C. and B. Snudden. 1982. Prevalence of Yersinia enterocolitica in waters of the lower
Chippewa river basin, Wisconsin. Appl. Environ. Microbiol. 43:953-954.
Wanger, A. 2007 Yersinia. In Murray, P., E. Baron, J. Jorgensen, M. Landry, and M. Pfaller
(ed.) The Manual of Clinical Microbiology, 9th. edition, American Society for Microbiology,
Washington, DC. Vol. 1: pp 689 - 690.
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