A Methodology for Classifying Root Causes of Outbreaks of Legionnaires' Disease: Deficiencies in Environmental Control and Water Management.

We piloted a methodology for collecting and interpreting root cause-or environmental deficiency (ED)-information from Legionnaires' disease (LD) outbreak investigation reports. The methodology included a classification framework to assess common failures observed in the implementation of water management programs (WMPs). We reviewed reports from fourteen CDC-led investigations between 1 January 2015 and 21 June 2019 to identify EDs associated with outbreaks of LD. We developed an abstraction guide to standardize data collection from outbreak reports and define relevant parameters. We categorized each ED according to three criteria: ED type, WMP-deficiency type, and source of deficiency. We calculated the prevalence of EDs among facilities and explored differences between facilities with and without WMPs. A majority of EDs identified (81%) were classified as process failures. Facilities with WMPs (n = 8) had lower prevalence of EDs attributed to plumbed devices (9.1%) and infrastructure design (0%) than facilities without WMPs (n = 6; 33.3% and 24.2%, respectively). About three quarters (72%) of LD cases and 81% of the fatalities in our sample originated at facilities without a WMP. This report highlights the importance of WMPs in preventing and mitigating outbreaks of LD. Building water system process management is a primary obstacle toward limiting the root causes of LD outbreaks. Greater emphasis on the documentation, verification, validation, and continuous program review steps will be important in maximizing the effectiveness of WMPs.

Public Health Responses to COVID-19 Outbreaks on Cruise Ships - Worldwide, February-March 2020.

An estimated 30 million passengers are transported on 272 cruise ships worldwide each year* (1). Cruise ships bring diverse populations into proximity for many days, facilitating transmission of respiratory illness (2). SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) was first identified in Wuhan, China, in December 2019 and has since spread worldwide to at least 187 countries and territories. Widespread COVID-19 transmission on cruise ships has been reported as well (3). Passengers on certain cruise ship voyages might be aged ≥65 years, which places them at greater risk for severe consequences of SARS-CoV-2 infection (4). During February-March 2020, COVID-19 outbreaks associated with three cruise ship voyages have caused more than 800 laboratory-confirmed cases among passengers and crew, including 10 deaths. Transmission occurred across multiple voyages of several ships. This report describes public health responses to COVID-19 outbreaks on these ships. COVID-19 on cruise ships poses a risk for rapid spread of disease, causing outbreaks in a vulnerable population, and aggressive efforts are required to contain spread. All persons should defer all cruise travel worldwide during the COVID-19 pandemic.

Identifying Needs for Advancing the Profession and Workforce in Environmental Health.

An ever-changing landscape for environmental health (EH) requires in-depth assessment and analysis of the current challenges and emerging issues faced by EH professionals. The Understanding the Needs, Challenges, Opportunities, Vision, and Emerging Roles in Environmental Health initiative addressed this need.After receiving responses from more than 1700 practitioners, during an in-person workshop, focus groups identified and described priority problems and supplied context on addressing the significant challenges facing EH professionals with state health agencies and local health departments. The focus groups developed specific problem statements detailing the EH profession and workforce's prevailing challenges and needs according to 6 themes, including effective leadership, workforce development, equipment and technology, information systems and data, garnering support, and partnerships and collaboration.We describe the identified priority problems and needs and provide recommendations for ensuring a strong and robust EH profession and workforce ready to address tomorrow's challenges.

Environmental Health Practice Challenges and Research Needs for U.S. Health Departments.

BACKGROUND: Environmental health (EH) professionals, one of the largest segments of the public health workforce, are responsible for delivery of essential environmental public health services. The challenges facing these professionals and research needs to improve EH practice are not fully understood, but 26% of EH professionals working in health departments of the United States plan to retire in 5 y, while only 6% of public health students are currently pursuing EH concentrations. OBJECTIVES: A groundbreaking initiative was recently launched to understand EH practice in health departments of the United States. This commentary article aims to identify priority EH practice challenges and related research needs for health departments. METHODS: A horizon scanning approach was conducted in which challenges facing EH professionals were provided by 1,736 respondents working at health departments who responded to a web-based survey fielded in November 2017. Thematic analyses of the responses and determining the frequency at which respondents reported specific issues and opportunities identified primary EH topic areas. These topic areas and related issues informed focus group discussions at an in-person workshop held in Anaheim, California. The purpose of the in-person workshop was to engage each of the topic areas and issues, through facilitated focus groups, leading to the formation of four to five related problem statements for each EH topic. DISCUSSION: EH professionals are strategically positioned to diagnose, intervene, and prevent public health threats. Focus group engagement resulted in 29 priority problem statements partitioned among 6 EH topic areas: a) drinking water quality, b) wastewater management, c) healthy homes, d) food safety, e) vectors and public health pests, and f) emerging issues. This commentary article identifies priority challenges and related research needs to catalyze effective delivery of essential environmental public health services for common EH program areas in health departments. An unprecedented initiative to revitalize EH practice with timely and strategic recommendations for student and professional training, nontraditional partnerships, and basic and translational research activities is recommended. https://doi.org/10.1289/EHP5161.

Uncovering Environmental Health: An Initial Assessment of the Profession's Health Department Workforce and Practice.

Environmental health (EH) professionals provide critical services and respond to complex and multifaceted public health threats. The role of these professionals is continually re-emphasized by emergencies requiring rapid and effective responses to address environmental issues and ensure protection of the public's health. Given the prominence of the EH profession within the public health framework, assessing the governmental health department workforce, practice, and current and future challenges is crucial to ensure EH professionals are fully equipped and prepared to protect the nation's health. Such an understanding of the EH profession is lacking; therefore, we initiated Understanding the Needs, Challenges, Opportunities, Vision, and Emerging Roles in Environmental Health (UNCOVER EH). Through a web-based survey, we identified EH professional demographics, characteristics, education, practice areas, and aspects of leadership and satisfaction. We distributed the survey to a convenience sample of EH professionals working in health departments, limiting the generalizability of results to the entire EH workforce. The results were strengthened, however, by purposive sampling strategies to represent varied professional and workforce characteristics in the respondent universe. The UNCOVER EH initiative provides a primary source of data to inform EH workforce development initiatives, improve the practice, and establish uniform benchmarks and professional competencies.

Organizational Characteristics of Local Health Departments and Environmental Health Services and Activities.

The main objective of this research was to ascertain the association between organizational characteristics of local health departments (LHDs) and environmental health (EH) services rendered in the community. Data used for the analysis were collected from LHDs by the National Association of County and City Health Officials for its 2013 national profile study of LHDs. We analyzed the data during 2016. Apart from understanding basic characteristics of LHDs in the nation, we introduced new measures of these characteristics, including "EH full-time equivalents" per 100,000 population and "other revenue" (revenues from fees and fines) per capita. The association of these and other organizational characteristics with EH services were measured using likelihood ratio χ2 and t-tests. Out of 34 EH services considered, LHDs directly provided an average of 12 different services. As many as 41% of the 34 EH services were not available in more than 10% of the communities served by LHDs. About 70% of communities received some services from organizations other than LHDs. All the available organizational characteristics of LHDs had association with some of the EH services. Although we might assume an increase in per capita expenditure could result in an increase in LHDs' direct involvement in providing EH services, we found it to be true only for five (15%) of the EH services. The variation of EH services provided in communities could be explained by a combination of factors such as fee generation, community needs, type of governance, and population size.

A Performance Management Initiative for Local Health Department Vector Control Programs.

Local health department (LHD) vector control programs have experienced reductions in funding and capacity. Acknowledging this situation and its potential effect on the ability to respond to vector-borne diseases, the U.S. Centers for Disease Control and Prevention and the Public Health Foundation partnered on a performance management initiative for LHD vector control programs. The initiative involved 14 programs that conducted a performance assessment using the Environmental Public Health Performance Standards. The programs, assisted by quality improvement (QI) experts, used the assessment results to prioritize improvement areas that were addressed with QI projects intended to increase effectiveness and efficiency in the delivery of services such as responding to mosquito complaints and educating the public about vector-borne disease prevention. This article describes the initiative as a process LHD vector control programs may adapt to meet their performance management needs. This study also reviews aggregate performance assessment results and QI projects, which may reveal common aspects of LHD vector control program performance and priority improvement areas. LHD vector control programs interested in performance assessment and improvement may benefit from engaging in an approach similar to this performance management initiative.

Blood Lead Levels Among Children Aged <6 Years - Flint, Michigan, 2013-2016.

During April 25, 2014-October 15, 2015, approximately 99,000 residents of Flint, Michigan, were affected by changes in drinking water quality after their water source was switched from the Detroit Water Authority (DWA), sourced from Lake Huron, to the Flint Water System (FWS), sourced from the Flint River.* Because corrosion control was not used at the FWS water treatment plant, the levels of lead in Flint tap water increased over time. Adverse health effects are associated with lead exposure (1). On January 2, 2015, a water advisory was issued because of detection of high levels of trihalomethanes, byproducts of disinfectants.(†)(,)(§) Studies conducted by local and national investigators detected an increase in the prevalence of blood lead levels (BLLs) ≥5 µg/dL (the CDC reference level) among children aged <5 years living in Flint (2) and an increase in water lead levels after the water source switch (3). On October 16, 2015, the Flint water source was switched back to DWA, and residents were instructed to use filtered tap water for cooking and drinking. During that time, pregnant and breastfeeding women and children aged <6 years were advised to consume bottled water.(¶) To assess the impact on BLLs of consuming contaminated drinking water, CDC examined the distribution of BLLs ≥5 µg/dL among children aged <6 years before, during, and after the switch in water source. This analysis enabled determination of whether the odds of having BLLs ≥5 µg/dL before the switch differed from the odds during the switch to FWS (before and after the January 2, 2015, water advisory was issued), and after the switch back to DWA. Overall, among 9,422 blood lead tests in children aged <6 years, 284 (3.0%) BLLs were ≥5 µg/dL during April 25, 2013-March 16, 2016. The adjusted probability of having BLLs ≥5 µg/dL was 46% higher during the period after the switch from DWA to FWS (and before the January 2, 2015, water advisory) than during the period before the water switch to FWS. Although unrelated to lead in the water, the water advisory likely reduced tap water consumption and increased consumption of bottled water. Characterizing exposure to lead contaminated drinking water among children aged <6 years living in Flint can help guide appropriate interventions.

Vital Signs: Deficiencies in Environmental Control Identified in Outbreaks of Legionnaires' Disease - North America, 2000-2014.

BACKGROUND: The number of reported cases of Legionnaires' disease, a severe pneumonia caused by the bacterium Legionella, is increasing in the United States. During 2000-2014, the rate of reported legionellosis cases increased from 0.42 to 1.62 per 100,000 persons; 4% of reported cases were outbreak-associated. Legionella is transmitted through aerosolization of contaminated water. A new industry standard for prevention of Legionella growth and transmission in water systems in buildings was published in 2015. CDC investigated outbreaks of Legionnaires' disease to identify gaps in building water system maintenance and guide prevention efforts. METHODS: Information from summaries of CDC Legionnaires' disease outbreak investigations during 2000-2014 was systematically abstracted, and water system maintenance deficiencies from land-based investigations were categorized as process failures, human errors, equipment failures, or unmanaged external changes. RESULTS: During 2000-2014, CDC participated in 38 field investigations of Legionnaires' disease. Among 27 land-based outbreaks, the median number of cases was 10 (range = 3-82) and median outbreak case fatality rate was 7% (range = 0%-80%). Sufficient information to evaluate maintenance deficiencies was available for 23 (85%) investigations. Of these, all had at least one deficiency; 11 (48%) had deficiencies in ≥2 categories. Fifteen cases (65%) were linked to process failures, 12 (52%) to human errors, eight (35%) to equipment failures, and eight (35%) to unmanaged external changes. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Multiple common preventable maintenance deficiencies were identified in association with disease outbreaks, highlighting the importance of comprehensive water management programs for water systems in buildings. Properly implemented programs, as described in the new industry standard, could reduce Legionella growth and transmission, preventing Legionnaires' disease outbreaks and reducing disease.

Outbreak of cryptosporidiosis associated with a man-made chlorinated lake--Tarrant County, Texas, 2008.

In July 2008, clusters of laboratory-confirmed cryptosporidiosis cases and reports of gastrointestinal illness in persons who visited a lake were reported to Tarrant County Public Health. In response, epidemiologic, laboratory, and environmental health investigations were initiated. A matched case-control study determined that swallowing the lake water was associated with illness (adjusted odds ratio = 16.3; 95% confidence interval: 2.5-infinity). The environmental health investigation narrowed down the potential sources of contamination. Laboratory testing detected Cryptosporidium hominis in case-patient stool specimens and Cryptosporidium species in lake water. It was only through the joint effort that epidemiologic, laboratory, and environmental health investigators could determine that >1 human diarrheal fecal incidents in the lake likely led to contamination of the water. This same collaborative effort will be needed to develop and maintain an effective national Model Aquatic Health Code.

A community demand-driven approach toward sustainable water and sanitation infrastructure development.

In September 2001, Cooperative Assistance and Relief Everywhere, Peru Country Office (CARE Peru), obtained funding from the United States Agency for International Development (USAID) to implement community-supported, condominial water and sanitation interventions in Manuel Cardozo Dávila, a settlement in Iquitos, Peru. With technical support from the Centers for Disease Control and Prevention (CDC), CARE Peru's Urban Environmental Health Models (Modelos Urbanos de Salud Ambiental [MUSA]) project built on previous work from implementing the Protocol for Assessing Community Excellence in Environmental Health in this same community. The project led to the municipal water supply distribution system being extended 1.3 kilometers into the Southern zone of Iquitos, where it connected to the condominial water system. Altogether, 1030 households were connected to the water supply system after the installation of a condominial water and sewerage system in Cardozo. Diarrheal disease decreased by 37% for children less than 5 years of age from 2003 to 2004. This paper illustrates the strategy used by CARE Peru in conjunction with the Cardozo community to assure that the local demand for improved water and sanitation was met.

Strengthening the capacity of local health agencies through community-based assessment and planning.

OBJECTIVES: We evaluated the effectiveness of the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) in building competency in essential environmental health services and renewing efforts to engage the community in problem solving. Competency and community engagement have been identified by environmental health practitioners as important to meet new threats to public health. METHODS: We conducted a national survey and 24 case studies of public health agencies. We invited 917 organizations to participate in the national survey because they had requested a copy of the protocol. RESULTS: We received 656 total responses: 354 had not considered implementation, 302 had considered implementation, and 66 had implemented PACE EH. For the 24 case studies, we interviewed 206 individuals in communities implementing PACE EH. We found that PACE EH has had a positive effect on building community and professional networks, enhancing leadership, developing workforce competence, and expanding definitions of environmental health practice. CONCLUSIONS: With appropriate investments, PACE EH can be an effective tool to meet the environmental health challenges identified by local environmental health practitioners and state, tribal, and federal agencies.

A waterborne outbreak of gastroenteritis with multiple etiologies among resort island visitors and residents: Ohio, 2004.

BACKGROUND: The implementation of treated municipal water systems in the 20th century led to a dramatic decrease in waterborne disease in the United States. However, communities with deficient water systems still experience waterborne outbreaks. In August 2004, we investigated an outbreak of gastroenteritis on South Bass Island, Ohio, an island of 900 residents that is visited by >500,000 persons each year. METHODS: To identify the source of illness, we conducted a case-control study and an environmental investigation. A case was defined as diarrhea in a person who traveled to the island during the period from May 1 through 30 September 2004 and became ill within 2 weeks after the visit. Healthy travel companions served as matched control subjects. We also performed an environmental assessment and extensive testing of island water sources. RESULTS: Among the 1450 persons reporting illness, Campylobacter jejuni, norovirus, Giardia intestinalis, and Salmonella enterica serotype Typhimurium were identified in 16, 9, 3, and 1 persons, respectively. We interviewed 100 case patients and 117 matched control subjects. Case patients were more likely to drink water on the island than control subjects (68% vs. 35%; matched odds ratio, 4.3; 95% confidence interval, 2.2-9.3). Sampling of ground water wells indicated contamination with multiple fecal microbes, including Escherichia coli, C. jejuni, Salmonella species, and Giardia species. Irregularities in sewage disposal practices that could have contaminated the underground aquifer were noted. CONCLUSIONS: The combined epidemiological and environmental investigation indicated that sewage-contaminated ground water was the likely source of this large outbreak. Long-term changes to the island's water supply and sewage management infrastructure are needed.

Beyond compliance: environmental health problem solving, interagency collaboration, and risk assessment to prevent waterborne disease outbreaks.

A systems approach to environmental health problem solving was used to investigate two waterborne norovirus outbreaks in Wyoming and can serve in the development of improved prevention strategies. An interagency collaboration to prevent waterborne disease involving local, state, and federal partners was designed to coordinate response to outbreak investigations. Improved risk assessment and reporting procedures were also integrated to ensure better availability of necessary data. Public health entities should implement sustainable intersectoral interventions to prevent waterborne disease that not only improve regulatory compliance but also have a positive impact on community health outcomes. Collaborative preventive health and water system protection activities should receive priority attention for implementation in state and local jurisdictions.

Use of a systems-based approach to an environmental health assessment for a waterborne disease outbreak investigation at a snowmobile lodge in Wyoming.

Investigations into disease outbreaks generally incorporate an epidemiologic investigation, laboratory analysis, and an environmental health assessment. This last component is designed to discover connections between factors in the environment and the outbreak, but is often limited, either by time and resources, or the expertise of the personnel included in outbreak investigation teams. A waterborne Norovirus outbreak investigation in Sheridan County, Wyoming, in 2001 provides an excellent example of the importance of including an in-depth, systems-based environmental health assessment in outbreak investigations. The epidemiologic component of this investigation identified the water supply of a snowmobile lodge in the Bighorn Mountains as the source of the outbreak, a result that was confirmed by laboratory analysis. Including a systems-based environmental health assessment in this investigation also helped to uncover the underlying environmental factors that led to contamination of the water supply. Those factors included an onsite wastewater disposal system that was overloaded by increased use and not well suited to local soil and geologic conditions and a drinking water system with no treatment or disinfection. In addition, heavy precipitation and increased pumping of wells to satisfy higher demands probably facilitated the contamination of the drinking water wells by causing greater movement of wastewater through the soil and underlying bedrock. By focusing on these links between factors in the environment and adverse health outcomes, the systems-based environmental health assessment also helped to highlight prevention strategies for avoiding recurrences.

Community environmental health assessment strengthens environmental public health services in the Peruvian Amazon.

In December 1999, the Centers for Disease Control and Prevention (CDC) and the Cooperative for Assistance and Relief Everywhere, Peru Country Office (CARE Peru), initiated the Urban Environmental Health Project (SAU, in Spanish) to strengthen environmental public health services in urban and periurban settlements in Peru. The project received funding from the Woodruff Foundation as part of the CARE-CDC Health Initiative (CCHI). The "Protocol for Assessing Community Excellence in Environmental Health" (PACE EH) guided the development of a community environmental public health assessment (CEHA) process in Cardozo, a settlement in Iquitos, Peru. The project developed a three-phase process that merged scientific understanding and community perception about local environmental health problems. In phase 1, local environmental health technicians assisted the community in understanding environmental health conditions in Cardozo and selecting priorities. During phase 2, local technicians assessed the community-selected priorities: water and sanitation. Results from recent water quality assessments revealed that 82% (9 of 11) of samples from shallow dug wells, 18% (2 of 11) from deeper drilled wells, and 61% (11/18) from household drinking containers were positive for thermotolerant coliforms. Phase 3 activities produced an action plan and an intervention to mitigate health problems associated with inadequate water and sanitation services in the Cardozo community. As a result of the CEHA process, CARE Peru obtained funding from the United States Agency for International Development (USAID) to develop and implement an environmental health risk monitoring system and the proposed water and sewage intervention in the settlement. CDC continues to provide technical assistance to the local environmental health services groups in Iquitos through an agreement with CARE Peru as part of the USAID-funded Urban Environmental Health Models Project (MUSA). Technical assistance activities and the development of the environmental health risk monitoring system have helped to strengthen the local environmental public health services delivery system.

Epidemiologic and environmental investigation of a recreational water outbreak caused by two genotypes of Cryptosporidium parvum in Ohio in 2000.

In August 2000, the Ohio Department of Health requested assistance to investigate a cryptosporidiosis outbreak with more than 700 clinical case-patients. An epidemiologic and environmental investigation was conducted. Stool specimens, pool water, and sand filter samples were analyzed. A community-based case-control study showed that the main risk factor was swimming in pool A (odds ratio [OR] = 42, 95% confidence interval [CI] = 12.3-144.9). This was supported by results of polymerase chain reaction (PCR) analysis, which showed the presence of both the human and bovine genotypes of Cryptosporidium parvum in case-patients and samples from the filter of pool A. A pool-based case-control study indicated that the highest risk was related to exposure to pool water via the mouth (OR = 5.1, 95% CI = 2.1-12.5) or to pool sprinklers (OR = 2.5, 95% CI = 1.3-4.7). Fecal accidents at the pool were documented. Records indicated that the pool met local health regulations. The outbreak, caused by co-infection with two C. parvum genotypes (human and bovine), underscores the need for concerted action to improve public health policies for recreational water facilities and enhanced education regarding the potential for disease transmission through pools.