Childhood iron deficiency anemia leads to recurrent respiratory tract infections and gastroenteritis.

Anemia affects approximately 30% of children all over the world. Acute respiratory tract infections (ARTI), urinary tract infections (UTI) and gastroenteritis (GE) are common infectious entities in children. Here, we assessed the association between anemia and development of recurrent ARTI, UTI, and GE in children. This was a case-control study in hospitalized 2-5 years old children in Professorial Pediatric Unit at Teaching Hospital Anuradhapura, Sri Lanka. An 18-month follow up was done to assess the risk factors for the development of recurrent ARTI, GE, UTI, and control presented without infections. Further, 6-month follow up done after 3-month iron supplementation to assess the occurrence of recurrences. Blood Hb concentration was measured using Drabking's reagent. Logistic regression was used to find the risk factors for the development of recurrences. In ARTI, 121/165 (73.3%), GE, 88/124 (71%), UTI 46/96 (47.9%) and control 40/100 (40%) were having anemia. Initial ARTI group, recurrent ARTI was 24 (14.5%, p = 0.03); initial GE group: recurrent GE was 14 (11.3%, p = 0.03), recurrent ARTI was 11 (8.9%, p = 0.04); initial UTI group, development of; recurrent UTI was 8 (8.3%, p = 0.04); control, recurrent ARTI was 11 (11%, p = 0.03). Following 3-month iron supplementation reduction of recurrences was significant: initial ARTI recurrent ARTI in 90%, recurrent GE in 77.7%; initial GE recurrent GE in 83.3%, recurrent ARTI in 80%; initial UTI recurrent ARTI in 71.4% and control recurrent ARTI in 88.8%. Iron deficiency is a major type of anemia and anemic children are more prone to develop recurrent ARTI and GE. Once iron deficiency being corrected the rate of recurrent ARTI and GE was reduced. This would be a boost for policy developers to implement strategies at the community level to prevent iron deficiency in children to reduce ARTI and GE recurrences.

[M'khinza-related intoxication: about two observations]. / Intoxication au M'khinza: à propos de deux observations.

Dysphania ambrosioides or anserine, known in Morocco as M'Khinza, is a plant belonging to family Chenopodiaceae. In Morocco, it is used for its therapeutic properties including, in particular, antipyretic properties. However, it can be toxic if it is incorrectly calibrated. We report two cases of poisoning whose data were collected in the Pediatric Emergency Department in Rabat. The study involved a 5-month old infant and a 10 year old girl with, respectively, toxic encephalopathy and severe dehydration associated with acute gastroenteritis after the ingestion of undetermined doses of infusion of this plant used as antipyretic. They both died in less than 12 hours. This study highlights the importance of considering M'Khinza-induced neurotoxicity and enterotoxicity in order to reach a correct diagnosis, the role of information and the need to fight against harmful consumption. Research on traditional pharmacopoeia should be encouraged in order to identify the therapeutic properties and to formalize, streamline and codify prescriptions.

A fermented milk concentrate and a combination of short-chain galacto-oligosaccharides/long-chain fructo-oligosaccharides/pectin-derived acidic oligosaccharides protect suckling rats from rotavirus gastroenteritis.

Human milk contains bioactive compounds that confer a protective role against gastrointestinal infections. In order to find supplements for an infant formula able to mimic these benefits of breast-feeding, two different concepts were tested. The products consisted of the following: (1) a Bifidobacterium breve- and Streptococcus thermophilus-fermented formula and (2) a combination of short-chain galacto-oligosaccharides/long-chain fructo-oligosaccharides with pectin-derived acidic oligosaccharides. A rotavirus infection suckling rat model was used to evaluate improvements in the infectious process and in the immune response of supplemented animals. Both nutritional concepts caused amelioration of the clinical symptoms, even though this was sometimes hidden by softer stool consistency in the supplemented groups. Both products also showed certain modulation of immune response, which seemed to be enhanced earlier and was accompanied by a faster resolution of the process. The viral shedding and the in vitro blocking assay suggest that these products are able to bind the viral particles, which can result in a milder infection. In conclusion, both concepts evaluated in this study showed interesting protective properties against rotavirus infection, which deserve to be investigated further.

OzFoodNet quarterly report, 1 April to 30 June 2015.

The Australian Government Department of Health established the OzFoodNet network in 2000 to collaborate nationally to investigate foodborne disease. In each Australian state and territory, OzFoodNet epidemiologists investigate outbreaks of enteric infection. In addition, OzFoodNet conducts studies on the burden of illness and coordinates national investigations into outbreaks of foodborne disease. This quarterly report documents investigations of outbreaks of gastrointestinal illness and clusters of disease potentially related to food, which commenced in Australia between 1 April and 30 June 2015. Data were received from OzFoodNet epidemiologists in all Australian states and territories. The data in this report are provisional and subject to change. During the 2nd quarter of 2015 (1 April to 30 June), OzFoodNet sites reported 352 outbreaks of enteric illness, including those transmitted by contaminated food or water. Outbreaks of gastroenteritis are often not reported to health authorities, which results in current figures under-representing the true burden of enteric disease outbreaks within Australia. There were 5,214 people affected in these outbreaks and 192 hospitalisations. There were 11 deaths reported during these outbreaks. This represents a decrease in the number of people affected compared with the 5-year average from 2010 to 2014 for the 2nd quarter (8,191). The majority of reported outbreaks of gastrointestinal illness in Australia are due to person-to-person transmission. In this quarter, 72% (255/352) of outbreaks were transmitted via this route (see Table 1). This percentage was similar to the same quarter in 2014 (73%, 305/419) but the total number is lower than the 5-year average (2nd quarter, 2010-2014) of 360 outbreaks transmitted person-to-person. Of the person-to-person outbreaks in the 2nd quarter of 2015, 47% (119/255) occurred in child care facilities and 40% (102/255) occurred in aged care facilities.

OzFoodNet quarterly report, 1 July to 30 September 2015.

The Australian Government Department of Health established the OzFoodNet network in 2000 to collaborate nationally to investigate foodborne disease. In each Australian state and territory, OzFoodNet epidemiologists investigate outbreaks of enteric infection. In addition, OzFoodNet conducts studies on the burden of illness and coordinates national investigations into outbreaks of foodborne disease. This quarterly report documents investigations of outbreaks of gastrointestinal illness and clusters of disease potentially related to food, which commenced in Australia between 1 July and 30 September 2015.

IBD-Like Features in Syndromic Diarrhea/Trichohepatoenteric Syndrome.

BACKGROUND: Very early onset inflammatory bowel disease (VEOIBD) (inflammatory bowel disease [IBD] before 6 years of age) may manifest as a monogenic disease affecting the gastrointestinal tract. Syndromic diarrhea/trichohepatoenteric syndrome (SD/THE), a rare disorder caused by alteration of a complex involved in RNA degradation, has been reported to present with some degree of colitis and in some cases an IBD-like presentation. METHODS: We reviewed clinical and biological data of 4 previously published cases and added detailed data of 2 new cases of SD/THE with an IBD-like presentation. RESULTS: All the 6 patients presented with typical intractable diarrhea and hair abnormalities. The colon was affected in all of the patients: 1 had ileitis, 2 had panenteritis, and 2 presented with perianal disease. Fecal calprotectin level and erythrosedimentation rate were elevated in 2 cases each. All the therapeutic classes of IBD treatment (mesalazine, steroids, immunomodulators, and biological therapy) were used in the 6 cases. In 2 patients, treatment had no effect. Three showed a partial effect, and 1 patient sustained only a transient effect. CONCLUSIONS: SD/THE can have a similar presentation as VEOIBD, often as pancolitis. IBD treatments appear to have little efficacy for SD/THE, suggesting a different pathogenesis for the IBD-like features in SD/THE compared with classical IBD.

Microbiota y enfermedades gastrointestinales / Microbiota and gastrointestinal diseases

La colonización bacteriana se establece inmediatamente después del nacimiento, por contacto directo con la microbiota materna, y puede modificarse durante la lactancia. Están apareciendo datos indicativos de que modificaciones cuantitativas y cualitativas de la microbiota intestinal son capaces de estimular cambios en la activación del sistema inmune que pueden conducir a la aparición de enfermedades gastrointestinales o extraintestinales. El equilibrio entre la microbiota patógena y beneficiosa durante la niñez y la adolescencia es importante para la salud gastrointestinal, incluyendo la protección frente a patógenos, la inhibición de patógenos, el procesamiento de nutrientes (síntesis de vitamina K), el estímulo de la angiogénesis y la regulación del almacenamiento de la grasa corporal. También los probióticos pueden modular la microbiota intestinal para favorecer la salud del huésped. Este artículo es una revisión sobre la acción moduladora de la microbiota intestinal en la prevención y el tratamiento coadyuvante de las enfermedades gastrointestinales pediátricas

The bacterial colonisation is established immediately after birth, through direct contact with maternal microbiota, and may be influenced during lactation. There is emerging evidence indicating that quantitative and qualitative changes on gut microbiota contribute to alterations in the mucosal activation of the immune system, leading to intra- or extra-intestinal diseases. A balance between pathogenic and beneficial microbiota throughout childhood and adolescence is important to gastrointestinal health, including protection against pathogens, inhibition of pathogens, nutrient processing (synthesis of vitamin K), stimulation of angiogenesis, and regulation of host fat storage. Probiotics can promote an intentional modulation of intestinal microbiota favouring the health of the host. A review is presented on the modulation of intestinal microbiota on prevention, and adjuvant treatment of some paediatric gastrointestinal diseases

Could the beneficial effects of dietary calcium on obesity and diabetes control be mediated by changes in intestinal microbiota and integrity?

Evidence from animal and human studies has associated gut microbiota, increased translocation of lipopolysaccharide (LPS) and reduced intestinal integrity (II) with the inflammatory state that occurs in obesity and type 2 diabetes mellitus (T2DM). Consumption of Ca may favour body weight reduction and glycaemic control, but its influence on II and gut microbiota is not well understood. Considering the impact of metabolic diseases on public health and the role of Ca on the pathophysiology of these diseases, this review critically discusses possible mechanisms by which high-Ca diets could affect gut microbiota and II. Published studies from 1993 to 2015 about this topic were searched and selected from Medline/PubMed, Scielo and Lilacs databases. High-Ca diets seem to favour the growth of lactobacilli, maintain II (especially in the colon), reduce translocation of LPS and regulate tight-junction gene expression. We conclude that dietary Ca might interfere with gut microbiota and II modulations and it can partly explain the effect of Ca on obesity and T2DM control. However, further research is required to define the supplementation period, the dose and the type of Ca supplement (milk or salt) required for more effective results. As Ca interacts with other components of the diet, these interactions must also be considered in future studies. We believe that more complex mechanisms involving extraintestinal disorders (hormones, cytokines and other biomarkers) also need to be studied.

Nutrient Intake by Ultramarathon Runners: Can They Meet Recommendations?

PURPOSE: The objective of this study was to investigate whether ultramarathon runners were able to meet nutrition recommendations during a training period and on a competition day. METHODS: In preparation for a 60 or 120 km ultramarathon covering a varied terrain, male and female ultramarathon runners (n = 68, age 46.5 ± 7.1 y) reported habitual dietary intake during three independent days using a web-based 24-hr recall and questionnaires. The diet was assessed using probability of inadequacy or by qualitative evaluation using reference dietary intakes or sports nutrition recommendations. A small group of 120 km runners (n = 4) was observed continuously during the race. After the race, 60 km runners (n = 41) received a questionnaire to assess dietary intake and gastrointestinal (GI) distress on the race day. Spearman rank correlation coefficients (r) were applied to investigate the association between intake and general GI distress symptoms. RESULTS: In men and women, habitual mean carbohydrate (CHO) intake was lower than recommended, as was mean protein intake by women. CHO intake during the race was <60 g/h in 75% of the athletes. A large variation of nutrient and fluid intake was seen. GI distress during the race was reported in 82% of the runners; severe GI distress was low. In general, moderate, mostly negative, correlations with nutrient intake were seen for GI distress. CONCLUSION: Sports nutrition recommendations for the habitual diet were not achieved. During a competition day, a large variation was found in nutrient intake; this may be related to a high incidence of GI distress.

Toxalbumin exposures: 12 years' experience of U.S. poison centers.

BACKGROUND: Toxalbumins are natural plant toxins purported to be highly toxic. The purpose was to evaluate toxalbumin exposures reported to U.S. poison centers to determine plants involved and their toxicities. METHODS: A retrospective review of National Poison Data System data on acute toxalbumin exposures with known outcomes from 2000 through 2011 was performed. RESULTS: There were 1164 exposures. The majority involved one route (1135; 97.5%), mostly ingestions (904; 79.7%) or dermal (166; 14.3%). Most patients developed no effects (694; 59.6%) or minor effects (374; 32.1%). Moderate or major effects occurred in 8.3% with 66.6% ingestions and 23.9% dermal. There were no deaths. Exposures to the plants Ricinus communis and Robinia pseudoacacia were most common (33.8% and 32.9%, respectively), with gastrointestinal effects from R. communis (vomiting 19.6%, diarrhea 8.9%, nausea 7.9%) and dermal effects from R. pseudoacacia (puncture 28.7%, dermal irritation/pain 27.9%, and edema 13.3%). CONCLUSIONS: While toxalbumin plant exposures were generally well-tolerated, continued evaluation of risk is warranted since plants were primarily identified by the public. Major effects occurred in under 1% of cases overall, and not at all following unintentional ingestions. These findings should help allay concerns that unintentional ingestions of toxalbumin plants by young children will cause serious toxicity and possibly death.

Notes from the field: Fatal gastrointestinal mucormycosis in a premature infant associated with a contaminated dietary supplement--Connecticut, 2014.

In October 2014, a hospital in Connecticut notified CDC and the Connecticut Department of Public Health of a fatal case of gastrointestinal mucormycosis in a preterm infant. The infant, born at 29 weeks' gestation and weighing 1,400 grams (about 3 pounds), had developed signs and symptoms initially consistent with necrotizing enterocolitis approximately 1 week after birth. Exploratory laparotomy revealed complete ischemia of the gastrointestinal tract from the esophagus to the rectum; a portion of necrotic cecum was sent for microscopic examination. Following surgery, the infant developed multiple areas of vascular occlusion, including a large clot in the aorta, findings not usually associated with necrotizing enterocolitis. The infant died soon after. Histopathology results from the resected cecum revealed an angioinvasive fungal infection consistent with mucormycosis. Gastrointestinal mucormycosis is an extremely rare fungal infection caused by mold in the order Mucorales. It occurs predominantly in low birth weight infants, patients with diarrhea and malnutrition, and those receiving peritoneal dialysis; mortality is 85%. Local investigation revealed that the infant had received a dietary supplement, ABC Dophilus Powder, for 7 days, beginning on day 1 of life.

Attitudes, beliefs, and barriers related to milk consumption in older, low-income women.

OBJECTIVE: To determine attitudes, beliefs, and barriers related to adequate milk consumption in low-income women ages ≥ 60 years. METHODS: Nine focus groups were conducted with a convenience sample of 59 women at congregate meal sites in a metropolitan area. Grounded in Social Cognitive Theory, focus group questions were used to explore personal, behavioral, and environmental factors associated with milk consumption. RESULTS: Key response themes indicated a positive attitude for the taste of milk (except for low-fat), a primary belief that milk was important for bones and health, and a primary barrier of gastrointestinal side effects. CONCLUSIONS AND IMPLICATIONS: Knowledge regarding the benefits of milk and the dislike of its taste were not the primary reason for the lack of consumption. Instead, gastrointestinal side effects seemed to be the major barrier to adequate consumption. Future nutrition campaigns should test strategies for lactose intolerance management when communicating with low-income older women.

Interaction of soyasaponins with plant ingredients in diets for Atlantic salmon, Salmo salar L.

The effects of combining soyasaponins with plant ingredients on intestinal function and fish health were investigated in an 80 d study with Atlantic salmon (270 g) distributed thirty each into twenty-four tanks with seawater. Soyasaponins were supplemented (2 g/kg) to diets with maize gluten (MG), pea protein concentrate (PPC) and sunflower (SFM), rapeseed (RSM) or horsebean meals. A diet with soyabean meal (SBM) and another with wheat gluten and soyasaponins served as reference diets. Marked soyasaponin effects were observed when combined with PPC. This combination induced inflammation in the distal intestine (DI) similar to SBM, reduced feed intake, apparent digestibility of lipid, most amino acids and ash, decreased bile salt levels in intestinal chyme and decreased leucine aminopeptidase (LAP) activity but increased trypsin activity in the DI. No enteritis was observed in other diet groups, but small consistent negative soyasaponin effects were seen on lipid and fatty acid digestibility, faecal DM and LAP activity of the DI. Soyasaponin combination with RSM reduced digestibility of all nutrients including minerals. The mineral effect was also seen for SFM, whereas with MG and SFM a positive soyasaponin effect on feed intake was observed. Caution should be exercised to avoid ingredient combinations giving high saponin levels, a condition that appears to be a key factor in diet-induced enteritis together with certain plant ingredients.

L-Carnitine and intestinal inflammation.

The intestinal barrier is one of the most dynamic surfaces of the body. It is here where a single layer of epithelial cells mediates the intricate encounters that occur between the host's immune system and a multitude of potential threats present in the intestinal lumen. Several key factors play an important role in the final outcome of this interaction, including the state of oxidative stress, the level of activation of the immune cells, and the integrity of the epithelial barrier. This chapter describes the main evidence demonstrating the impact that l-carnitine has on each of these factors. These findings, combined with the demonstrated safety profile of l-carnitine, underscore the potential therapeutic value of l-carnitine supplementation in humans suffering from intestinal inflammation and highlight the functional data supporting an association between Crohn's disease and mutations in the l-carnitine transporter genes.

Protection against early intestinal compromise by lipid-rich enteral nutrition through cholecystokinin receptors.

OBJECTIVE: Early gut wall integrity loss and local intestinal inflammation are associated with the development of inflammatory complications in surgical and trauma patients. Prevention of these intestinal events is a potential target for therapies aimed to control systemic inflammation. Previously, we demonstrated in a rodent shock model that lipid-rich enteral nutrition attenuated systemic inflammation and prevented organ damage through a cholecystokinin receptor-dependent vagal pathway. The influence of lipid-rich nutrition on very early intestinal compromise as seen after shock is investigated. Next, the involvement of cholecystokinin receptors on the nutritional modulation of immediate gut integrity loss and intestinal inflammation is studied. DESIGN: Randomized controlled in vivo study. SETTING: University research unit. SUBJECTS: Male Sprague-Dawley rats. INTERVENTIONS: Liquid lipid-rich nutrition or control low-lipid feeding was administered per gavage before hemorrhagic shock. Cholecystokinin receptor antagonists were used to investigate involvement of the vagal antiinflammatory pathway. MEASUREMENTS AND MAIN RESULTS: Gut permeability to horseradish peroxidase increased as soon as 30 mins postshock and was prevented by lipid-rich nutrition compared with low-lipid (p<.01) and fasted controls (p<.001). Furthermore, lipid-rich nutrition reduced plasma levels of enterocyte damage marker ileal lipid binding protein at 60 mins (p<.05). Early gut barrier dysfunction correlated with rat mast cell protease plasma concentrations at 30 mins (rs=0.67; p<.001) and intestinal myeloperoxidase levels at 60 mins (rs=0.58; p<.05). Lipid-rich nutrition significantly reduced plasma rat mast cell protease (p<.01) and myeloperoxidase (p<.05) before systemic inflammation was detectable. Protective effects of lipid-rich nutrition were abrogated by cholecystokinin receptor antagonists (horseradish peroxidase; p<.05 and rat mast cell protease; p<.05). CONCLUSIONS: Lipid-rich enteral nutrition prevents early gut barrier loss, enterocyte damage, and local intestinal inflammation before systemic inflammation develops in a cholecystokinin receptor-dependent manner. This study identifies activation of the vagal antiinflammatory pathway with lipid-rich nutrition as a potential therapy in patients prone to develop a compromised gut.

A mineral-rich red algae extract inhibits polyp formation and inflammation in the gastrointestinal tract of mice on a high-fat diet.

The purpose of this study was to determine whether a mineral-rich extract derived from the red marine algae Lithothamnion calcareum could be used as a dietary supplement for chemoprevention against colon polyp formation. A total of 60 C57bl/6 mice were divided into 3 groups based on diet. One group received a low-fat, rodent chow diet (AIN76A). The second group received a high-fat "Western-style" diet (HFWD). The third group was fed the same HFWD with the mineral-rich extract included as a dietary supplement. Mice were maintained on the respective diets for 15 months. Autopsies were performed at the time of death or at the completion of the study. To summarize, the cumulative mortality rate was higher in mice on the HFWD during the 15-month period (55%) than in mice from the low-fat diet or the extract-supplemented high-fat diet groups (20% and 30%, respectively; P < .05 with respect to both). Autopsies revealed colon polyps in 20% of the animals on the HFWD and none in animals of the other 2 groups (P < .05). In addition to the grossly visible polyps, areas of hyperplasia in the colonic mucosa and inflammatory foci throughout the gastrointestinal tract were observed histologically in animals on the high-fat diet. Both were significantly reduced in animals on the low-fat diet and animals on the extract-supplemented HFWD.These data suggest that the mineral-rich algae extract may provide a novel approach to chemoprevention in the colon.

An outbreak of Salmonella gastrointestinal illness in a military camp.

INTRODUCTION: Non-typhoidal Salmonellae are important causes of bacterial food-borne infection, especially in institutional settings. An outbreak of gastrointestinal infection occurred in a military camp in January 2007, and an epidemiological outbreak investigation was conducted. MATERIALS AND METHODS: A survey was conducted on soldiers in the camp on their clinical symptoms, and recent meals consumed. After determining the affected meal, a subsequent survey was conducted on those who had eaten the meal. A case-control study was then performed to determine the outbreak's likely food source. Laboratory tests were also conducted to determine the bacteriological cause. RESULTS: Of the 94 responders, 55 (58.5%) met our case definition of gastrointestinal illness. The dinner on 9 January was the most likely affected meal, with the onset of symptoms occurring within 6 to 36 hours. The mashed potato was the most likely food source with an attack rate of 80.7% for those who consumed it versus 32.7% for those who did not (P <0.01). From the multivariate analysis, the mashed potato remained the only food item independently and significantly associated with infection, with a relative risk of infection 9.49 times those who did not consume it (95% CI, 2.73-32.97). Salmonella group E was cultured from 4 individuals. Although no specific contamination was identified, the mashed potato was stored for more than 5 hours before the last serving. CONCLUSION: Risk during preparation of large quantities of food should be identified a priori, and measures taken to reduce them, to prevent outbreaks.

Possible antioxidant role of SPA therapy with chlorine-sulphur-bicarbonate mineral water.

The aim of our research was to analyze the antioxidant role and efficacy of thermal or salus per aquam (spa) therapy with chlorine-sulphur-bicarbonate mineral water. The study has been performed on 30 rats. The animals were randomized in three groups, each of them composed by ten animals, denominated A, B and C. The A group was the control group and was not subjected to any specific treatment (placebo); the B group has been treated with a standard cycle of hydropinics treatment with mineral water of Therme of Stabia in Castellammare (Naples, Italy) denominated STABIA; the C group was treated with a standard cycle of hydropinic treatment with mineral water of Therme of Stabia in Castellammare (Naples, Italy) denominated SULFUREA. After two weeks of treatment all the rats were sacrificed and blood was collected for the plasmatic determination of reactive oxygen species (ROS). The results demonstrated a significant (P < 0.05) reduction of ROS in B (374 Carr. U. +/-73) and C group (399 carr. U. +/-62) treated with mineral waters if compared with control group (571 + 69 Carr. U.). In conclusion this study suggests a possible antioxidant effect of chlorine-sulphur-bicarbonate spa hydropinic treatment with a consequent suitable intestinal physiology, with reduction of the functional and organic modifications that can lead to pathological disorders of the gastroenteric diseases in whose pathogenesis the oxidative stress can develop an important role.

Surveillance for waterborne disease and outbreaks associated with recreational water use and other aquatic facility-associated health events--United States, 2005-2006.

PROBLEM/CONDITION: Since 1971, CDC, the U.S. Environmental Protection Agency, and the Council of State and Territorial Epidemiologists have collaboratively maintained the Waterborne Disease and Outbreak Surveillance System for collecting and reporting data related to waterborne-disease outbreaks (WBDOs) associated with drinking water. In 1978, WBDOs associated with recreational water (natural and treated water) were added. This system is the primary source of data regarding the scope and effects of disease associated with recreational water in the United States. In addition, data are collected on individual cases of recreational water-associated illnesses and infections and health events occurring at aquatic facilities but not directly related to water exposure. REPORTING PERIOD: Data presented summarize WBDOs and case reports associated with recreational water use that occurred during January 2005--December 2006 and previously unreported disease reports and outbreaks during 1978--2004. DESCRIPTION OF THE SYSTEM: Public health departments in the states, territories, localities, and the Freely Associated States (i.e., the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau, formerly parts of the U.S.-administered Trust Territory of the Pacific Islands) have primary responsibility for detecting, investigating, and voluntarily reporting WBDOs to CDC. Although the surveillance system includes data for WBDOs and cases associated with drinking water, recreational water, and water not intended for drinking, only cases and outbreaks associated with recreational water and health events at aquatic facilities are summarized in this report. RESULTS: During 2005--2006, a total of 78 WBDOs associated with recreational water were reported by 31 states. Illness occurred in 4,412 persons, resulting in 116 hospitalizations and five deaths. The median outbreak size was 13 persons (range: 2--2,307 persons). Of the 78 WBDOs, 48 (61.5%) were outbreaks of gastroenteritis that resulted from infectious agents or chemicals; 11 (14.1%) were outbreaks of acute respiratory illness; and 11 (14.1%) were outbreaks of dermatitis or other skin conditions. The remaining eight were outbreaks of leptospirosis (n = two), primary amebic meningoencephalitis (n = one), and mixed or other illnesses (n = five). WBDOs associated with gastroenteritis resulted in 4,015 (91.0%) of 4,412 illnesses. Fifty-eight (74.4%) WBDOs occurred at treated water venues, resulting in 4,167 (94.4%) cases of illness. The etiologic agent was confirmed in 62 (79.5%) of the 78 WBDOs, suspected in 12 (15.4%), and unidentified in four (5.1%). Thirty-four (43.6%) WBDOs had a parasitic etiology; 22 (28.2%), bacterial; four (5.1%), viral; and two (2.6%), chemical or toxin. Among the 48 gastroenteritis outbreaks, Cryptosporidium was confirmed as the causal agent in 31 (64.6%), and all except two of these outbreaks occurred in treated water venues where Cryptosporidium caused 82.9% (29/35) of the gastroenteritis outbreaks. Case reports associated with recreational water exposure that were discussed and analyzed separately from outbreaks include three fatal Naegleria cases and 189 Vibrio illnesses reported to the Cholera and Other Vibrio Illness Surveillance System. For Vibrio reporting, the most commonly reported species were Vibrio vulnificus, V. alginolyticus, and V. parahaemolyticus. V. vulnificus illnesses associated with recreational water exposure had the highest Vibrio illness hospitalization (77.6%) and mortality (22.4%) rates. In addition, 32 aquatic facility-related health events not associated with recreational water use (e.g., pool chemical mixing accidents) that occurred during 1983--2006 were received from New York. These events, which caused illness in 364 persons, are included in this report but analyzed separately. INTERPRETATIONS: The number of WBDOs summarized in this report and the trends in recreational water-associated disease and outbreaks demonstrate a substantial increase in number of reports from previous years. Outbreaks, especially the largest ones, occurred more frequently in the summer at treated water venues and caused gastrointestinal illness. Deficiencies leading to WBDOs included problems with water-quality, venue design, usage, and maintenance. Case reports of illness associated with recreational water use expand our understanding of the scope of waterborne illness by further underscoring the contribution of less well-recognized swimming venues (e.g., oceans) and illness (e.g., nongastrointestinal illness). Aquatic facilities are also a focus for injuries involving chemicals or equipment used routinely in the operation of swimming venues, thus illustrating the lack of training of some aquatics staff. PUBLIC HEALTH ACTIONS: CDC uses WBDO surveillance data to 1) identify the etiologic agents, types of aquatic venues, water-treatment systems, and deficiencies associated with outbreaks and case reports; 2) evaluate the adequacy of efforts (i.e., regulations and public awareness activities) to provide safe recreational water; 3) expand the scope of understanding about waterborne disease and health events associated with swimming and aquatics facilities; and 4) establish public health prevention priorities, data, and messaging that might lead to improved regulations, guidelines, and prevention measures at the local, state, and federal levels.