Healthcare Provider Confidence and Perceived Barriers to Diagnosing Illness Associated with Harmful Algal Blooms.

Introduction: Illnesses caused by harmful algal blooms can vary in clinical presentation and severity depending on the types of algae, cyanobacteria, or toxins involved as well as the route and extent of exposure. These illnesses are primarily diagnoses of exclusion owing to lack of access to clinical testing for harmful algal bloom toxins. We used a national survey of healthcare providers to explore self-reported confidence and perceived barriers to diagnosing harmful algal bloom-associated illnesses. Methods: We conducted a descriptive analysis (SAS 9.4) of 2 questions from a national survey of healthcare providers administered September 14-October 26, 2020 (N=1,503). Chi-square tests were used to assess differences between groups, with statistical significance defined as p<0.05. Results: Most (68%) providers reported little to no confidence in their ability to identify illnesses caused by harmful algal blooms, 17% were confident or very confident, and 15% reported not seeing patients with these illnesses. Responses differed by specialization, work setting, sex, experience, whether pediatric patients were seen, and number of patients seen. Respondents regularly using resources such as newspapers (31%), professional societies (29%), and government health agencies (26%) reported increased confidence. Of 1,283 (85%) respondents who were asked about barriers to accurately diagnosing patients with these illnesses, 71% selected lack of knowledge about harmful algal bloom-associated illnesses as a barrier. Conclusions: Provider confidence in identifying harmful algal bloom-associated illnesses was low, and lack of knowledge was identified as a primary barrier, suggesting that more outreach and education are needed. Tailoring information for specific provider audiences and providing it through highly frequented channels could increase providers' confidence in identifying and diagnosing harmful algal bloom-associated illnesses.

Surveillance for Harmful Algal Bloom Events and Associated Human and Animal Illnesses - One Health Harmful Algal Bloom System, United States, 2016-2018.

Harmful algal bloom events can result from the rapid growth, or bloom, of photosynthesizing organisms in natural bodies of fresh, brackish, and salt water. These events can be exacerbated by nutrient pollution (e.g., phosphorus) and warming waters and other climate change effects (1); have a negative impact on the health of humans, animals, and the environment; and damage local economies (2,3). U.S. harmful algal bloom events of public health concern are centered on a subset of phytoplankton: diatoms, dinoflagellates, and cyanobacteria (also called blue-green algae). CDC launched the One Health Harmful Algal Bloom System (OHHABS) in 2016 to inform efforts to prevent human and animal illnesses associated with harmful algal bloom events. A total of 18 states reported 421 harmful algal bloom events, 389 cases of human illness, and 413 cases of animal illness that occurred during 2016-2018. The majority of harmful algal bloom events occurred during May-October (413; 98%) and in freshwater bodies (377; 90%). Human and animal illnesses primarily occurred during June-September (378; 98%) and May-September (410; 100%). Gastrointestinal or generalized illness signs or symptoms were the most frequently reported (>40% of human cases and >50% of animal cases); however, multiple other signs and symptoms were reported. Surveillance data from harmful algal bloom events, exposures, and health effects provide a systematic description of these occurrences and can be used to inform control and prevention of harmful algal bloom-associated illnesses.

Outbreaks Associated with Untreated Recreational Water - United States, 2000-2014.

Outbreaks associated with untreated recreational water can be caused by pathogens, toxins, or chemicals in fresh water (e.g., lakes, rivers) or marine water (e.g., ocean). During 2000-2014, public health officials from 35 states and Guam voluntarily reported 140 untreated recreational water-associated outbreaks to CDC. These outbreaks resulted in at least 4,958 cases of disease and two deaths. Among the 95 outbreaks with a confirmed infectious etiology, enteric pathogens caused 80 (84%); 21 (22%) were caused by norovirus, 19 (20%) by Escherichia coli, 14 (15%) by Shigella, and 12 (13%) by Cryptosporidium. Investigations of these 95 outbreaks identified 3,125 cases; 2,704 (87%) were caused by enteric pathogens, including 1,459 (47%) by norovirus, 362 (12%) by Shigella, 314 (10%) by Cryptosporidium, and 155 (5%) by E. coli. Avian schistosomes were identified as the cause in 345 (11%) of the 3,125 cases. The two deaths were in persons affected by a single outbreak (two cases) caused by Naegleria fowleri. Public parks (50 [36%]) and beaches (45 [32%]) were the leading settings associated with the 140 outbreaks. Overall, the majority of outbreaks started during June-August (113 [81%]); 65 (58%) started in July. Swimmers and parents of young swimmers can take steps to minimize the risk for exposure to pathogens, toxins, and chemicals in untreated recreational water by heeding posted advisories closing the beach to swimming; not swimming in discolored, smelly, foamy, or scummy water; not swimming while sick with diarrhea; and limiting water entering the nose when swimming in warm freshwater.

Outbreaks Associated with Treated Recreational Water - United States, 2000-2014.

Outbreaks associated with exposure to treated recreational water can be caused by pathogens or chemicals in venues such as pools, hot tubs/spas, and interactive water play venues (i.e., water playgrounds). During 2000-2014, public health officials from 46 states and Puerto Rico reported 493 outbreaks associated with treated recreational water. These outbreaks resulted in at least 27,219 cases and eight deaths. Among the 363 outbreaks with a confirmed infectious etiology, 212 (58%) were caused by Cryptosporidium (which causes predominantly gastrointestinal illness), 57 (16%) by Legionella (which causes Legionnaires' disease, a severe pneumonia, and Pontiac fever, a milder illness with flu-like symptoms), and 47 (13%) by Pseudomonas (which causes folliculitis ["hot tub rash"] and otitis externa ["swimmers' ear"]). Investigations of the 363 outbreaks identified 24,453 cases; 21,766 (89%) were caused by Cryptosporidium, 920 (4%) by Pseudomonas, and 624 (3%) by Legionella. At least six of the eight reported deaths occurred in persons affected by outbreaks caused by Legionella. Hotels were the leading setting, associated with 157 (32%) of the 493 outbreaks. Overall, the outbreaks had a bimodal temporal distribution: 275 (56%) outbreaks started during June-August and 46 (9%) in March. Assessment of trends in the annual counts of outbreaks caused by Cryptosporidium, Legionella, or Pseudomonas indicate mixed progress in preventing transmission. Pathogens able to evade chlorine inactivation have become leading outbreak etiologies. The consequent outbreak and case counts and mortality underscore the utility of CDC's Model Aquatic Health Code (https://www.cdc.gov/mahc) to prevent outbreaks associated with treated recreational water.

Waterborne Disease Outbreaks Associated With Environmental and Undetermined Exposures to Water - United States, 2013-2014.

Waterborne disease outbreaks in the United States are associated with a wide variety of water exposures and are reported annually to CDC on a voluntary basis by state and territorial health departments through the National Outbreak Reporting System (NORS). A majority of outbreaks arise from exposure to drinking water (1) or recreational water (2), whereas others are caused by an environmental exposure to water or an undetermined exposure to water. During 2013-2014, 15 outbreaks associated with an environmental exposure to water and 12 outbreaks with an undetermined exposure to water were reported, resulting in at least 289 cases of illness, 108 hospitalizations, and 17 deaths. Legionella was responsible for 63% of the outbreaks, 94% of hospitalizations, and all deaths. Outbreaks were also caused by Cryptosporidium, Pseudomonas, and Giardia, including six outbreaks of giardiasis caused by ingestion of water from a river, stream, or spring. Water management programs can effectively prevent outbreaks caused by environmental exposure to water from human-made water systems, while proper point-of-use treatment of water can prevent outbreaks caused by ingestion of water from natural water systems.

Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water - United States, 2013-2014.

Provision of safe water in the United States is vital to protecting public health (1). Public health agencies in the U.S. states and territories* report information on waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS) (https://www.cdc.gov/healthywater/surveillance/index.html). During 2013-2014, 42 drinking water-associated† outbreaks were reported, accounting for at least 1,006 cases of illness, 124 hospitalizations, and 13 deaths. Legionella was associated with 57% of these outbreaks and all of the deaths. Sixty-nine percent of the reported illnesses occurred in four outbreaks in which the etiology was determined to be either a chemical or toxin or the parasite Cryptosporidium. Drinking water contamination events can cause disruptions in water service, large impacts on public health, and persistent community concern about drinking water quality. Effective water treatment and regulations can protect public drinking water supplies in the United States, and rapid detection, identification of the cause, and response to illness reports can reduce the transmission of infectious pathogens and harmful chemicals and toxins.