Brett-Major, David

Brett-Major, Sherry M.

English

University of Nebraska Medical Center Research: DigitalCommons@UNMC

University of Nebraska Medical Center DigitalCommons@UNMC Journal Articles: Epidemiology Epidemiology 2007 Water Source Outbreaks, Policy, and the South Bass Island Investigation David Brett-Major Sherry M. Brett-Major Follow this and additional works at: https://digitalcommons.unmc.edu/coph_epidem_articles  Part of the Epidemiology Commons 666 • CID 2007:45 (1 September) • CORRESPONDENCE2. Walsh TJ, Hiemenz JW, Seibel NL, et al. Am-photericin B lipid complex for invasive fungalinfections: analysis of safety and efficacy in 556cases. Clin Infect Dis 1998; 26:1383–96.3. Denning DW, Lee JY, Hostetler JS, et al.NIAID Mycoses Study Group multicenter trialof oral itraconazole therapy for invasive as-pergillosis. Am J Med 1994; 97:135–44.4. Walsh TJ, Lutsar I, Driscoll T, et al. Voricon-azole in the treatment of aspergillosis, sce-dosporiosis, and other invasive fungal infec-tions in children. Pediatr Infect Dis J 2002;21:240–8.5. Baden LR, Katz JT, Fishman JA, et al. Salvagetherapy with voriconazole for invasive fungalinfections in patients failing or intolerant tostandard antifungal therapy. Transplantation2003; 76:1632–7.6. Ascioglu S, Rex JH, de Pauw B, et al. Definingopportunistic invasive fungal infections in im-munocompromised patients with cancer andhematopoietic stem cell transplants: an inter-national consensus. Clin Infect Dis 2002; 34:7–14.7. Baden LR, Marty FM. Posaconazole for in-vasive aspergillosis [letter]? Clin Infect Dis2007; 45:664 (in this issue).8. Oakley KL, Moore CB, Denning DW. In vitroactivity of SCH-56592 and comparison withactivities of amphotericin B and itraconazoleagainst Aspergillus spp. Antimicrob AgentsChemother 1997; 41:1124–6.9. Imai JK, Singh G, Clemons KV, Stevens DA.Efficacy of posaconazole in a murine modelof central nervous system aspergillosis. Anti-microb Agents Chemother 2004; 48:4063–6.10. Petraitiene R, Petraitis V, Groll AH, et al. An-tifungal activity and plasma pharmacokineticsof posaconazole (SCH 56592) in treatmentand prevention of experimental invasive pul-monary aspergillosis: correlation with galac-tomannan antigenemia. Antimicrob AgentsChemother 2001; 45:857–69.11. Najvar LK, Cacciapuoti A, Hernandez S, et al.Activity of posaconazole combined with am-photericin B against Aspergillus flavus infec-tion in mice: comparative studies in two lab-oratories. Antimicrob Agents Chemother2004; 48:758–64.12. Kirkpatrick WR, McAtee RK, Fothergill AW,Loebenberg D, Rinaldi MG, Patterson TF. Ef-ficacy of SCH56592 in a rabbit model of in-vasive aspergillosis. Antimicrob Agents Che-mother 2000; 44:780–2.13. Walsh TJ, Petraitis V, Petraitiene R, et al. Ex-perimental pulmonary aspergillosis due to As-pergillus terreus: pathogenesis and treatmentof an emerging fungal pathogen resistant toamphotericin B. J Infect Dis 2003; 188:305–19.Reprints or correspondence: Dr. Thomas J. Walsh, PediatricOncology Branch, National Cancer Institute, NIH, CRC 1-5750,10 Center Dr., Bethesda, MD 20892 (walsht@mail.nih.gov).Clinical Infectious Diseases 2007; 45:665–6Q 2007 by the Infectious Diseases Society of America. Allrights reserved. 1058-4838/2007/4505-0025$15.00DOI: 10.1086/521971Water Source Outbreaks,Policy, and the South BassIsland InvestigationTo the Editor—We applaud O’Reilly etal. [1] on their hard work emphasizing thekey point that public hygiene matters. Ob-viously, they undertook exhaustive watersampling and an extensive survey of pa-tient exposures to characterize the out-break of gastroenteritis on South Bass Is-land, Lake Erie, Ohio. Liang et al. [2]provided a broad view of the importanceof quality assurance and diligence in main-taining the domestic water supply fromthe perspective of outbreaks. In their re-cent survey of outbreaks in the UnitedStates, Liang and colleagues found that150% of incidents occurred in areas out-side the jurisdiction of a water utility. TheEnvironmental Protection Agency recentlypublished a Ground Water Rule [3] thattargets the quality assurance responsibili-ties of water utilities but does not neces-sarily fill the gap between regulations thatprotect designated watershed areas and theneed for supported community ap-proaches to respond to concerns once theyare realized. O’Reilly et al. [1] suggest thatthe answer for South Bass Island is a mu-nicipal water treatment facility. Capitali-zation and maintenance costs of such anintervention are high. A subsidized well-water outlet purification approach, whichwould be encouraged for households andmandatory for commercial establish-ments, may be a better option in some ofthese settings. World Health Organizationguidelines on water quality provide an ex-cellent summary of pathogens and appro-priate targets for purification (includingtoxins) based on background water con-tamination levels, and they cite acceptedefficacies for a wide range of purificationmethods appropriate at the municipal,well, and household levels [4]. Open-minded cost and efficacy analyses for eachcommunity are needed, because rapid, af-fordable, and efficacious interventionsmay be available and less daunting thanlarge infrastructure projects or—thoughimportant—sewage control and abate-ment in the Great Lakes.The mere presence of pathogens insampled well water is not surprising. Weare curious to know the concentrations ofand intersource variance in pathogensidentified in this outbreak. Also, althoughwe are familiar with karst systems, we wereconfused by figure 2 in the article [1]. Thedepicted well appears to draw from aground water source but is contaminatedby surface water. Proper well placementavoids surface water. As represented, thewell appears to draw from the bottom ofthe aquifer. If so, this is problematic, be-cause settleable solids, such as organismsand contaminants heavier than water, maythen be drawn into the well. The goal isnot to disturb this layer for precisely thereasons highlighted in this article.AcknowledgmentsPotential conflicts of interest. D.M.B. andS.M.B.: no conflicts.David M. Brett-Major1and Sherry M. Brett-Major21Department of Internal Medicine, Division ofInfectious Diseases, National Naval Medical Center,Bethesda, Maryland; and 2Catholic University ofAmerica Columbus School of Law, Washington DCReferences1. O’Reilly CE, Bowen AB, Perez NE, et al. Awaterborne outbreak of gastroenteritis withmultiple etiologies among resort island visitorsand residents: Ohio, 2004. Clin Infect Dis2007; 44:506–12.2. Liang JL, Dziuban EJ, Craun GF, et al. Sur-veillance for waterborne disease and outbreaksassociated with drinking water and water notintended for drinking—United States,2003–2004. MMWR Surveill Summ 2006; 55:31–65.3. US Environmental Protection Agency. EPAGround Water Rule. US Environmental Pro-tection Agency, 2006. Available at: http://www.epa.gov/safewater/disinfection/gwr/regulation.html. Accessed 8 April 2007.4. World Heath Organization. World Heath Or-ganization Guidelines for drinking-water qual-ity, third edition. Geneva: World HealthOrganization, 2004. Available at: http://www.who.int/water_sanitation_health/dwq/gdwq3/en/. Accessed 8 April 2007.Downloaded from https://academic.oup.com/cid/article/45/5/666/275913 by University of Nebraska Medical Center McGoogan Library user on 02 December 2021CORRESPONDENCE • CID 2007:45 (1 September) • 667The views expressed are those of the authors and do notrepresent those of the US Navy, the Department of Defense,the US Government, or the Catholic University of America.Reprints or correspondence: Dr. David M. Brett-Major, Infec-tious Diseases, NNMC, 8901 Wisconsin Ave., Bethesda, MD20889 (BrettMajor@aol.com).Clinical Infectious Diseases 2007; 45:666–7Q 2007 by the Infectious Diseases Society of America. Allrights reserved. 1058-4838/2007/4505-0026$15.00DOI: 10.1086/521971Reply to Brett-Major andBrett-MajorTo the Editor—We thank Brett-Majorand Brett-Major [1] for their correspon-dence and appreciate their interest in andconcerns regarding access to safe drinkingwater after a large, waterborne outbreakof gastroenteritis on South Bass Island,Lake Erie, Ohio [2]. There is no doubtthat access to safe drinking water is anessential component of health protectionin communities. We agree that point-of-use water treatment is the most appro-priate strategy in the provision of safedrinking water for certain communities,particularly in the developing world [3, 4],and well-water outlet purification may bean option for areas outside water utilityjurisdiction. However, on South Bass Is-land, a highly developed island that re-ceives 1500,000 tourists every year, wemaintain that expansion of the existingmunicipal water treatment infrastructureis the most appropriate solution for safedrinking water on this island. We do notimply that municipal water treatment isthe solution for all islands or for all areasthat have an underlying karst hydrogeol-ogy. In fact, we think that, in the contextof an outbreak, it is prudent to performan extensive environmental assessment, sothat the most appropriate solution for theenvironmental scenario can be identified.Multiple sources of contamination wereevident from the exposure informationcollected in the epidemiological and en-vironmental studies. Multiple fecal mi-crobes were identified in ground waterwells throughout the island. Of the subsetof water samples for which quantificationwas performed, many contained relativelyhigh concentrations of fecal contaminants.The results of all environmental samplingon the island during the outbreak are pub-licly available in a series of reports pre-pared by the multiple agencies involved inthe investigation (http://www.odh.ohio.gov/news/lcmv1.aspx).In our article [2], figure 2 is a repre-sentation of the basic concepts of groundwater and surface water flow in karst ter-rain [5]. An unfortunate characteristic ofkarst geology is, indeed, the fact thatground water can come under the influ-ence of surface water. The investigationfound that contamination at shallow welldepths was greatest, and many wells wereunprotected from shallow contaminationas a result of the short lengths of casing(6–8 m [20–27 feet]) installed in the well.Furthermore, a review of the island welllogs found that more than one-half of thewells had openings, crevices, or caves be-low the protective casing depth. These fac-tors may have allowed surface water andcontaminants to quickly reach and enterthe wells [6, 7]. Island wells may drawfrom a range of points in the aquifer. Weagree that, as noted, wells should not drawfrom the bottom of the aquifer. For thesereasons, the safety of water from wellsplaced in a karst geology can not beguaranteed.We appreciate the opportunity to ex-pand on some of the specifics of this out-break. We hope lessons learned from thisoutbreak may help communities deter-mine the appropriate approach to ensuresafe water for their residents and visitors.AcknowledgmentsWe acknowledge and thank our colleagues onthe Outbreak Investigation Working Group andall members of the outbreak investigative team.Potential conflicts of interest. All authors: noconflicts.Ciara E. O’Reilly,1 Vincent Hill,2and Michael F. Lynch,1 on behalf of theOutbreak Investigation Working Group1Enteric Diseases Epidemiology Branch, Division ofFoodborne, Bacterial and Mycotic Diseases, and2Division of Parasitic Diseases, Centers for DiseaseControl and Prevention, Atlanta, GeorgiaReferences1. Brett-Major DM, Brett-Major SM. Water andpublic hygiene [letter]. Clin Infect Dis 2007;45:666–7 (in this issue).2. O’Reilly CE, Bowen AB, Perez NE, et al. Awaterborne outbreak of gastroenteritis withmultiple etiologies among resort island visitorsand residents: Ohio, 2004. Clin Infect Dis2007; 44:506–12.3. Centers for Disease Control and Prevention.Safe water systems for the developing world: ahandbook for implementing household-basedwater treatment and safe storage projects. At-lanta: Centers for Disease Control and Preven-tion, 2000. Available at: http://www.cdc.gov/safewater/manual/sws_manual.pdf. AccessedApril 2007.4. Mintz E, Bartram J, Lochery P, Wegelin M. Notjust a drop in the bucket: expanding access topoint-of-use water treatment systems. Am JPublic Health 2001; 91:1565–70.5. Grannemann NG, Hunt RJ, Nicholas JR, et al.The importance of ground water in the GreatLakes region. Water Resources Investigation re-port 00–4008. Lansing, MI: US Geological Sur-vey, Office of Ground Water, 2000.6. Keswick BH. Sources of groundwater pollution.In: Britton G, Gerba CP, eds. Groundwater pol-lution microbiology. New York: John Wiley &Sons, 1984:39–64.7. US Department of the Interior. Groundwatermanual—a water resource technical publica-tion. Denver, Bureau of Reclamation, US Gov-ernment Printing Office, 1985.Reprints or correspondence: Dr. Ciara O’Reilly, Enteric Dis-eases Epidemiology Branch, Div. of Foodborne, Bacterial andMycotic Diseases, Centers for Disease Control and Preven-tion, 1600 Clifton Rd. NE, MS A-38, Atlanta, GA 30333(coreilly@cdc.gov).Clinical Infectious Diseases 2007; 45:667This article is in the public domain, and no copyright isclaimed. 1058-4838/2007/4505-0027$15.00DOI: 10.1086/521971Liposomal Amphotericin BTrial Marred by ConclusionsTo the Editor—We commend Cornelyet al. [1] for their excellent study com-paring 2 different doses of liposomal am-photericin B (LAmB) as initial therapy forinvasive mold infection. The study was de-signed to answer the important questionof whether a dosage of 10 mg/kg per dayof LAmB is more effective than a dosageof 3 mg/kg per day during the first 2 weeksof treatment.Unfortunately, some of the authors’ as-sertions are not supported by the data pre-sented. We disagree with the authors’Downloaded from https://academic.oup.com/cid/article/45/5/666/275913 by University of Nebraska Medical Center McGoogan Library user on 02 December 2021

Water Source Outbreaks, Policy, and the South Bass Island Investigation

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Water Source Outbreaks, Policy, and the South Bass Island Investigation

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