Epidemiology and estimated costs of a large waterborne outbreak of norovirus infection in Sweden.

A large outbreak of norovirus (NoV) gastroenteritis caused by contaminated municipal drinking water occurred in Lilla Edet, Sweden, 2008. Epidemiological investigations performed using a questionnaire survey showed an association between consumption of municipal drinking water and illness (odds ratio 4·73, 95% confidence interval 3·53-6·32), and a strong correlation between the risk of being sick and the number of glasses of municipal water consumed. Diverse NoV strains were detected in stool samples from patients, NoV genotype I strains predominating. Although NoVs were not detected in water samples, coliphages were identified as a marker of viral contamination. About 2400 (18·5%) of the 13,000 inhabitants in Lilla Edet became ill. Costs associated with the outbreak were collected via a questionnaire survey given to organizations and municipalities involved in or affected by the outbreak. Total costs including sick leave, were estimated to be ∼8,700,000 Swedish kronor (∼€0·87 million).

Waterborne norovirus outbreak in a municipal drinking-water supply in Sweden.

During Easter 2009, almost 200 people resident in a small Swedish village fell ill with gastrointestinal symptoms. We conducted a retrospective cohort study and a molecular investigation in order to identify the source of the outbreak. Residents living in households connected to the public water network were at an increased risk of developing disease (relative risk 4·80, 95% confidence interval 1·68-13·73) compared to those with no connection to the public network. Norovirus genotype GI.3 was identified in stool samples from six patients and in a sample from the public water network. Contamination of one of the wells supplying the public water network was thought to be the source of the outbreak. This is a description of a norovirus outbreak linked to a municipal drinking-water supply in Sweden. Information from epidemiological and molecular investigations is of utmost importance to guide outbreak control measures and to prevent future outbreaks.

A large Escherichia coli O157 outbreak in Sweden associated with locally produced lettuce.

In 2005 a large outbreak of verotoxin-producing Escherichia coli (VTEC) occurred in Sweden. Cases were interviewed and cohort and case-control studies were conducted. Microbiological investigations were performed using polymerase chain reaction (PCR) to detect the Shiga-like toxin (Stx) genes followed by cultivation and pulsed-field gel electrophoresis. A total of 135 cases were recorded, including 11 cases of hemolytic uremic syndrome. The epidemiological investigations implicated lettuce as the most likely source of the outbreak, with an OR of 13.0 (CI 2.94-57.5) in the case-control study. The lettuce was irrigated by water from a small stream, and water samples were positive for Stx 2 by PCR. The identical VTEC O157 Stx 2 positive strain was isolated from the cases and in cattle at a farm upstream from the irrigation point. An active surveillance and reporting system was crucial and cooperation between all involved parties was essential for quickly identifying the cause of this outbreak. Handling of fresh greens from farm to table must be improved to minimize the risk of contamination.

A case-cohort study to investigate concomitant waterborne outbreaks of Campylobacter and gastroenteritis in Söderhamn, Sweden, 2002-3.

Increased domestic, laboratory confirmed, Campylobacter notifications were reported in Siderhamn municipality, December 2002 and January 2003. Concurrently, during preliminary investigations a large outbreak of acute gastroenteritis was detected. Simultaneously, two studies were completed to identify risk factors for infection with Campylobacter and acute gastrointestinal infection (AGI): (1) a case-cohort study using Campylobacter cases (N = 101) with a large random sample from the municipal population as referents (N = 1000) and (2) a retrospective cohort study for the outcome AGI using the same sample. A postal questionnaire was used to collect demographic, clinical, water and food consumption data. Measures of association (risk ratio (RR), odds ratio (OR)) and 95% confidence intervals (CI) were calculated. Stool, environmental and water samples were tested by standard methods at Gävle Hospital and SMI laboratories respectively. In the case-cohort study, Camplylobacter cases were more likely than referents to consume communal water (OR = 12.6 (95% CI 1.7-92.3)). In the cohort study, risk of gastroenteritis was 2.3 times higher in those who consumed water (AR = 27.3%) than others (AR = 12%). Risk of illness was associated with the amount of water consumed in both studies. Campylobacter was detected in stools and Escherichia coli (E. coli) from routine communal water (CW) samples. Results suggest both Söderhamn outbreaks of Campylobacter and AGI were associated with consumption of CW. The method used strengthened epidemiological evidence and was efficient in the use of time and resources.

Biochemical fingerprinting of water coliform bacteria, a new method for measuring phenotypic diversity and for comparing different bacterial populations.

A simple, automated microplate system for biochemical characterization of water isolates can be used to obtain fingerprints of the bacterial flora from various water samples. Mathematical models for calculating the diversities and similarities between bacterial populations are described for such fingerprints. The diversity may give information on whether an indigenous or allochthonous flora is present, and the similarities between bacterial populations, as calculated by using a population similarity coefficient (Sp), may indicate contaminations between different water samples. The system was demonstrated on coliform bacterial populations from various water samples, with or without suspected intercontamination. For unrelated water samples, the Sps were close to 0, whereas repeated samples of the same source showed Sps of 0.64 to 0.74. The Sp values from several water samples were also clustered to form a dendrogram, thus indicating the relative similarities between the bacterial populations to confirm suspected common sources of pollution.

Improved recovery of Legionella from water samples by use of black membrane filters.

A higher recovery of Legionella bacteria from water samples was achieved using black filters that were directly placed on agar plates after filtration, compared to the traditional method using white filters that are shaken in buffer after filtration. Up to 100 times more Legionella colonies/100 ml were found using black filters compared to the traditional method. The two filtration methods revealed, however, no big differences with pure culture experiments. Treatment with acid solution, directly on the filters without dilution of the concentrated sample, effectively reduced the number of accompanying bacteria.

Diversity, persistence, and virulence of Aeromonas strains isolated from drinking water distribution systems in Sweden.

The Aeromonas populations in 13 Swedish drinking water distribution systems, representing different treatments, were investigated. From each system, water samples were collected four times during the period from May to September 1994 from raw water and water after treatment and at two to five sites within the distribution system. In total, 220 water samples were collected. From samples containing presumptive Aeromonas, up to 32 colonies were analyzed by the PhenePlate Aeromonas (PhP-AE) system, which is a highly discriminating biochemical fingerprinting method. Selected isolates from different phenotypes (PhP types) were further identified by the API 20 NE system and by gas-liquid chromatography analysis of fatty acid methyl esters (FAMEs). Selected isolates were also assayed for their potential to produce hemolysin and cytotoxin and for their ability to adhere to human intestinal cells. In total, 117 water samples (53%) contained presumptive Aeromonas which numbered up to 10(6) CFU/100 ml in raw water and up to 750 CFU/100 ml in tap water. Among the 2,117 isolates that were subjected to typing by the PhP-AE system, more than 300 distinct PhP types were found, of which the majority occurred only sporadically. Raw (surface) water samples usually contained many different PhP types, showing high diversity indices (Di) (median Di = 0.95). The Aeromonas populations in samples collected from within the distribution systems were less diverse (median Di = 0.58) and were often dominated by one major PhP type that was found on several sampling occasions. Seventeen such major PhP types could be found and were represented in 1,037 isolates (49%). Identification by API 20 NE and FAME analysis revealed that most of the major PhP types were Aeromonas hydrophila or belonged to unidentified Aeromonas species. Hemolysin and cytotoxin production was observed in most major PhP types (representing 87 and 54% of the assayed isolates, respectively), and adherence was found in 89% of the isolates that produced cytotoxin. Thus, the data presented here show that although raw water may contain very diverse Aeromonas populations, the populations seemed to be remarkably stable within the studied water distribution systems, and that some potentially pathogenic Aeromonas strains could persist for several months in drinking water.