Surveillance for waterborne disease and outbreaks associated with recreational water--United States, 2003-2004

MMWR Surveill Summ. 2006 Dec 22;55(12):1-30.


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 waterborne disease and outbreak (WBDO)-related data. 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 WBDOs in the United States.

Reporting period: Data presented summarize WBDOs associated with recreational water that occurred during January 2003-December 2004 and one previously unreported outbreak from 2002.

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 associated with drinking water, recreational water, and water not intended for drinking, only cases and outbreaks associated with recreational water are summarized in this report.

Results: During 2003-2004, a total 62 WBDOs associated with recreational water were reported by 26 states and Guam. Illness occurred in 2,698 persons, resulting in 58 hospitalizations and one death. The median outbreak size was 14 persons (range: 1-617 persons). Of the 62 WBDOs, 30 (48.4%) were outbreaks of gastroenteritis that resulted from infectious agents, chemicals, or toxins; 13 (21.0%) were outbreaks of dermatitis; and seven (11.3%) were outbreaks of acute respiratory illness (ARI). The remaining 12 WBDOs resulted in primary amebic meningoencephalitis (n = one), meningitis (n = one), leptospirosis (n = one), otitis externa (n = one), and mixed illnesses (n = eight). WBDOs associated with gastroenteritis resulted in 1,945 (72.1%) of 2,698 illnesses. Forty-three (69.4%) WBDOs occurred at treated water venues, resulting in 2,446 (90.7%) cases of illness. The etiologic agent was confirmed in 44 (71.0%) of the 62 WBDOs, suspected in 15 (24.2%), and unidentified in three (4.8%). Twenty (32.3%) WBDOs had a bacterial etiology; 15 (24.2%), parasitic; six (9.7%), viral; and three (4.8%), chemical or toxin. Among the 30 gastroenteritis outbreaks, Cryptosporidium was confirmed as the causal agent in 11 (36.7%), and all except one of these outbreaks occurred in treated water venues where Cryptosporidium caused 55.6% (10/18) of the gastroenteritis outbreaks. In this report, 142 Vibrio illnesses (reported to the Cholera and Other Vibrio Illness Surveillance System) that were associated with recreational water exposure were analyzed separately. 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 (87.2%) and mortality (12.8%) rates.

Interpretation: The number of WBDOs summarized in this report and the trends in recreational water-associated disease and outbreaks are consistent with previous years. Outbreaks, especially the largest ones, are most likely to be associated with summer months, treated water venues, and gastrointestinal illness. Approximately 60% of illnesses reported for 2003-2004 were associated with the seven largest outbreaks (>100 cases). Deficiencies leading to WBDOs included problems with water quality, venue design, usage, and maintenance.

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; 2) evaluate the adequacy of efforts (i.e., regulations and public awareness activities) to provide safe recreational water; and 3) establish public health prevention priorities that might lead to improved regulations and prevention measures at the local, state, and federal levels.

MeSH terms

  • Bathing Beaches*
  • Communicable Diseases / epidemiology*
  • Disease Outbreaks*
  • Humans
  • Population Surveillance
  • Recreation
  • Rivers*
  • Swimming Pools*
  • United States / epidemiology
  • Water Microbiology*
  • Water Pollution*