Last data update: Oct 28, 2024. (Total: 48004 publications since 2009)
Records 1-28 (of 28 Records) |
Query Trace: Kunz J[original query] |
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Factors associated with legionella detection in the water systems of national lodging organization facilities with water management programs in the United States
Kahn R , Derado G , Hannapel EJ , Vander Kelen P , Kunz JM , Edens C . Int J Environ Res Public Health 2024 21 (7) A better understanding of risk factors and the predictive capability of water management program (WMP) data in detecting Legionella are needed to inform the efforts aimed at reducing Legionella growth and preventing outbreaks of Legionnaires' disease. Using WMPs and Legionella testing data from a national lodging organization in the United States, we aimed to (1) identify factors associated with Legionella detection and (2) assess the ability of WMP disinfectant and temperature metrics to predict Legionella detection. We conducted a logistic regression analysis to identify WMP metrics associated with Legionella serogroup 1 (SG1) detection. We also estimated the predictive values for each of the WMP metrics and SG1 detection. Of 5435 testing observations from 2018 to 2020, 411 (7.6%) had SG1 detection, and 1606 (29.5%) had either SG1 or non-SG1 detection. We found failures in commonly collected WMP metrics, particularly at the primary test point for total disinfectant levels in hot water, to be associated with SG1 detection. These findings highlight that establishing and regularly monitoring water quality parameters for WMPs may be important for preventing Legionella growth and subsequent disease. However, while unsuitable water quality parameter results are associated with Legionella detection, this study found that they had poor predictive value, due in part to the low prevalence of SG1 detection in this dataset. These findings suggest that Legionella testing provides critical information to validate if a WMP is working, which cannot be obtained through water quality parameter measurements alone. |
Automated cooling tower detection through deep learning for Legionnaires' disease outbreak investigations: a model development and validation study
Wong KK , Segura T , Mein G , Lu J , Hannapel EJ , Kunz JM , Ritter T , Smith JC , Todeschini A , Nugen F , Edens C . Lancet Digit Health 2024 6 (7) e500-e506 BACKGROUND: Cooling towers containing Legionella spp are a high-risk source of Legionnaires' disease outbreaks. Manually locating cooling towers from aerial imagery during outbreak investigations requires expertise, is labour intensive, and can be prone to errors. We aimed to train a deep learning computer vision model to automatically detect cooling towers that are aerially visible. METHODS: Between Jan 1 and 31, 2021, we extracted satellite view images of Philadelphia (PN, USA) and New York state (NY, USA) from Google Maps and annotated cooling towers to create training datasets. We augmented training data with synthetic data and model-assisted labelling of additional cities. Using 2051 images containing 7292 cooling towers, we trained a two-stage model using YOLOv5, a model that detects objects in images, and EfficientNet-b5, a model that classifies images. We assessed the primary outcomes of sensitivity and positive predictive value (PPV) of the model against manual labelling on test datasets of 548 images, including from two cities not seen in training (Boston [MA, USA] and Athens [GA, USA]). We compared the search speed of the model with that of manual searching by four epidemiologists. FINDINGS: The model identified visible cooling towers with 95·1% sensitivity (95% CI 94·0-96·1) and a PPV of 90·1% (95% CI 90·0-90·2) in New York City and Philadelphia. In Boston, sensitivity was 91·6% (89·2-93·7) and PPV was 80·8% (80·5-81·2). In Athens, sensitivity was 86·9% (75·8-94·2) and PPV was 85·5% (84·2-86·7). For an area of New York City encompassing 45 blocks (0·26 square miles), the model searched more than 600 times faster (7·6 s; 351 potential cooling towers identified) than did human investigators (mean 83·75 min [SD 29·5]; mean 310·8 cooling towers [42·2]). INTERPRETATION: The model could be used to accelerate investigation and source control during outbreaks of Legionnaires' disease through the identification of cooling towers from aerial imagery, potentially preventing additional disease spread. The model has already been used by public health teams for outbreak investigations and to initialise cooling tower registries, which are considered best practice for preventing and responding to outbreaks of Legionnaires' disease. FUNDING: None. |
Shiga toxin-producing Escherichia coli o157:H7 illness outbreak associated with untreated, pressurized, municipal irrigation water - Utah, 2023
Osborn B , Hatfield J , Lanier W , Wagner J , Oakeson K , Casey R , Bullough J , Kache P , Miko S , Kunz J , Pederson G , Leeper M , Strockbine N , McKeel H , Hofstetter J , Roundtree A , Kahler A , Mattioli M . MMWR Morb Mortal Wkly Rep 2024 73 (18) 411-416 During July-September 2023, an outbreak of Shiga toxin-producing Escherichia coli O157:H7 illness among children in city A, Utah, caused 13 confirmed illnesses; seven patients were hospitalized, including two with hemolytic uremic syndrome. Local, state, and federal public health partners investigating the outbreak linked the illnesses to untreated, pressurized, municipal irrigation water (UPMIW) exposure in city A; 12 of 13 ill children reported playing in or drinking UPMIW. Clinical isolates were genetically highly related to one another and to environmental isolates from multiple locations within city A's UPMIW system. Microbial source tracking, a method to indicate possible contamination sources, identified birds and ruminants as potential sources of fecal contamination of UPMIW. Public health and city A officials issued multiple press releases regarding the outbreak reminding residents that UPMIW is not intended for drinking or recreation. Public education and UPMIW management and operations interventions, including assessing and mitigating potential contamination sources, covering UPMIW sources and reservoirs, indicating UPMIW lines and spigots with a designated color, and providing conspicuous signage to communicate risk and intended use might help prevent future UPMIW-associated illnesses. |
Surveillance of waterborne disease outbreaks associated with drinking water - United States, 2015-2020
Kunz JM , Lawinger H , Miko S , Gerdes M , Thuneibat M , Hannapel E , Roberts VA . MMWR Surveill Summ 2024 73 (1) 1-23 PROBLEM/CONDITION: Public health agencies in U.S. states, territories, and freely associated states investigate and voluntarily report waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS). This report summarizes NORS drinking water outbreak epidemiologic, laboratory, and environmental data, including data for both public and private drinking water systems. The report presents outbreak-contributing factors (i.e., practices and factors that lead to outbreaks) and, for the first time, categorizes outbreaks as biofilm pathogen or enteric illness associated. PERIOD COVERED: 2015-2020. DESCRIPTION OF SYSTEM: CDC launched NORS in 2009 as a web-based platform into which public health departments voluntarily enter outbreak information. Through NORS, CDC collects reports of enteric disease outbreaks caused by bacterial, viral, parasitic, chemical, toxin, and unknown agents as well as foodborne and waterborne outbreaks of nonenteric disease. Data provided by NORS users, when known, for drinking water outbreaks include 1) the number of cases, hospitalizations, and deaths; 2) the etiologic agent (confirmed or suspected); 3) the implicated type of water system (e.g., community or individual or private); 4) the setting of exposure (e.g., hospital or health care facility; hotel, motel, lodge, or inn; or private residence); and 5) relevant epidemiologic and environmental data needed to describe the outbreak and characterize contributing factors. RESULTS: During 2015-2020, public health officials from 28 states voluntarily reported 214 outbreaks associated with drinking water and 454 contributing factor types. The reported etiologies included 187 (87%) biofilm associated, 24 (11%) enteric illness associated, two (1%) unknown, and one (<1%) chemical or toxin. A total of 172 (80%) outbreaks were linked to water from public water systems, 22 (10%) to unknown water systems, 17 (8%) to individual or private systems, and two (0.9%) to other systems; one (0.5%) system type was not reported. Drinking water-associated outbreaks resulted in at least 2,140 cases of illness, 563 hospitalizations (26% of cases), and 88 deaths (4% of cases). Individual or private water systems were implicated in 944 (43%) cases, 52 (9%) hospitalizations, and 14 (16%) deaths.Enteric illness-associated pathogens were implicated in 1,299 (61%) of all illnesses, and 10 (2%) hospitalizations. No deaths were reported. Among these illnesses, three pathogens (norovirus, Shigella, and Campylobacter) or multiple etiologies including these pathogens resulted in 1,225 (94%) cases. The drinking water source was identified most often (n = 34; 7%) as the contributing factor in enteric disease outbreaks. When water source (e.g., groundwater) was known (n = 14), wells were identified in 13 (93%) of enteric disease outbreaks.Most biofilm-related outbreak reports implicated Legionella (n = 184; 98%); two nontuberculous mycobacteria (NTM) (1%) and one Pseudomonas (0.5%) outbreaks comprised the remaining. Legionella-associated outbreaks generally increased over the study period (14 in 2015, 31 in 2016, 30 in 2017, 34 in 2018, 33 in 2019, and 18 in 2020). The Legionella-associated outbreaks resulted in 786 (37%) of all illnesses, 544 (97%) hospitalizations, and 86 (98%) of all deaths. Legionella also was the outbreak etiology in 160 (92%) public water system outbreaks. Outbreak reports cited the premise or point of use location most frequently as the contributing factor for Legionella and other biofilm-associated pathogen outbreaks (n = 287; 63%). Legionella was reported to NORS in 2015 and 2019 as the cause of three outbreaks in private residences (2). INTERPRETATION: The observed range of biofilm and enteric drinking water pathogen contributing factors illustrate the complexity of drinking water-related disease prevention and the need for water source-to-tap prevention strategies. Legionella-associated outbreaks have increased in number over time and were the leading cause of reported drinking water outbreaks, including hospitalizations and deaths. Enteric illness outbreaks primarily linked to wells represented approximately half the cases during this reporting period. This report enhances CDC efforts to estimate the U.S. illness and health care cost impacts of waterborne disease, which revealed that biofilm-related pathogens, NTM, and Legionella have emerged as the predominant causes of hospitalizations and deaths from waterborne- and drinking water-associated disease. PUBLIC HEALTH ACTION: Public health departments, regulators, and drinking water partners can use these findings to identify emerging waterborne disease threats, guide outbreak response and prevention programs, and support drinking water regulatory efforts. |
Effects of the COVID-19 pandemic on legionella water management program performance across a United States lodging organization
Kunz JM , Hannapel E , Vander Kelen P , Hils J , Hoover ER , Edens C . Int J Environ Res Public Health 2023 20 (19) Legionella, the bacterium that causes Legionnaires' disease, can grow and spread in building water systems and devices. The COVID-19 pandemic impacted building water systems through reductions in water usage. Legionella growth risk factors can be mitigated through control measures, such as flushing, to address stagnation, as part of a water management program (WMP). A national lodging organization (NLO) provided WMP data, including Legionella environmental testing results for periods before and during the pandemic. The statistical analysis revealed an increased risk of water samples testing positive for Legionella during the pandemic, with the greatest increase in risk observed at the building's cold-water entry test point. Sample positivity did not vary by season, highlighting the importance of year-round Legionella control activities. The NLO's flushing requirements may have prevented an increased risk of Legionella growth during the pandemic. However, additional control measures may be needed for some facilities that experience Legionella detections. This analysis provides needed evidence for the use of flushing to mitigate the impacts of building water stagnation, as well as the value of routine Legionella testing for WMP validation. Furthermore, this report reinforces the idea that WMPs remain the optimal tool to reduce the risk of Legionella growth and spread in building water systems. |
Estimating waterborne infectious disease burden by exposure route, United States, 2014
Gerdes ME , Miko S , Kunz JM , Hannapel EJ , Hlavsa MC , Hughes MJ , Stuckey MJ , Francois Watkins LK , Cope JR , Yoder JS , Hill VR , Collier SA . Emerg Infect Dis 2023 29 (7) 1357-1366 More than 7.15 million cases of domestically acquired infectious waterborne illnesses occurred in the United States in 2014, causing 120,000 hospitalizations and 6,600 deaths. We estimated disease incidence for 17 pathogens according to recreational, drinking, and nonrecreational nondrinking (NRND) water exposure routes by using previously published estimates. In 2014, a total of 5.61 million (95% credible interval [CrI] 2.97-9.00 million) illnesses were linked to recreational water, 1.13 million (95% CrI 255,000-3.54 million) to drinking water, and 407,000 (95% CrI 72,800-1.29 million) to NRND water. Recreational water exposure was responsible for 36%, drinking water for 40%, and NRND water for 24% of hospitalizations from waterborne illnesses. Most direct costs were associated with pathogens found in biofilms. Estimating disease burden by water exposure route helps direct prevention activities. For each exposure route, water management programs are needed to control biofilm-associated pathogen growth; public health programs are needed to prevent biofilm-associated diseases. |
Notes from the Field: Legionnaires disease in a U.S. traveler after staying in a private vacation rental house in the U.S. Virgin Islands - United States, February 2022
Mac VV , Labgold K , Moline HL , Smith JC , Carroll J , Clemmons N , Edens C , Ellis B , Harrison C , Henderson KC , Ishaq MK , Kozak-Muiznieks NA , Kunz J , Lawrence M , Lucas CE , Walker HL , Willby MJ , Ellis EM . MMWR Morb Mortal Wkly Rep 2023 72 (20) 564-565 On February 1, 2022, the U.S. Virgin Islands (USVI) Department of Health (VIDOH) was notified of a confirmed case of Legionnaires disease in an adult U.S. resident (Figure). The patient, a man aged 55 years, returned to his U.S. state of residence from leisure travel in USVI on January 22 and developed a cough, shortness of breath, and fatigue on January 23. On January 29, he was hospitalized for shortness of breath and received a positive SARS-CoV-2 test result at admission. The combination of the patient’s symptoms and recent travel history prompted administration of a urinary antigen test (UAT) for Legionnaires disease specific to Legionella pneumophila serogroup 1 (Lp1); a positive result was returned on January 31. Inpatient treatment administered for COVID-19 pneumonia and Legionnaires disease included remdesivir, oral levofloxacin, oral and intravenous steroid therapy, and as-needed use of a bronchodilator inhaler and an expectorant. Remdesivir was discontinued during inpatient treatment because of elevated liver enzymes. The patient recovered and was discharged on February 2. |
Legionnaires' disease outbreak associated with a hot tub display at the North Carolina Mountain State Fair, September 2019
Donovan CV , MacFarquhar JK , Wilson E , Sredl M , Tanz LJ , Mullendore J , Fleischauer A , Smith JC , Lucas C , Kunz J , Moore Z . Public Health Rep 2023 139 (1) 333549231159159 OBJECTIVES: On September 23, 2019, the North Carolina Division of Public Health identified a legionellosis increase in western North Carolina; most patients had recently attended the North Carolina Mountain State Fair. We conducted a source investigation. METHODS: Cases were fair attendees with laboratory-confirmed legionellosis and symptom onset within 2 to 14 days (Legionnaires' disease) or ≤3 days (Pontiac fever). We conducted a case-control study matching cases to non-ill fair attendees as control participants and an environmental investigation, and we performed laboratory testing (Legionella bacteria culture and polymerase chain reaction) of 27 environmental samples from fairgrounds and hot tubs and 14 specimens from case patients. We used multivariable unconditional logistic regression models to calculate adjusted odds ratios for potential Legionella exposure sources and risk factors. RESULTS: Of 136 people identified with fair-associated legionellosis, 98 (72%) were hospitalized and 4 (3%) died. Case patients were more likely than control participants to report walking by hot tub displays (adjusted odds ratio = 10.0; 95% CI, 4.2-24.1). Complete hot tub water treatment records were not kept, precluding evaluation of water maintenance conducted on display hot tubs. Legionella pneumophila sequence types (STs) were consistent among 10 typed clinical specimens (ST224) but distinct from the only positive environmental sample from the fair (ST7 and ST8). CONCLUSIONS: Hot tub displays were identified as the most likely outbreak source, making this the largest hot tub-associated Legionnaires' disease outbreak worldwide. Following the investigation, the North Carolina Division of Public Health and the Centers for Disease Control and Prevention released guidance on mitigating risk of Legionella exposure from hot tub displays. Results highlight the importance of properly maintaining equipment that aerosolizes water, including hot tubs intended for display purposes only. |
Dialysis Water Supply Faucet as Reservoir for Carbapenemase-Producing Pseudomonas aeruginosa
Prestel C , Moulton-Meissner H , Gable P , Stanton RA , Glowicz J , Franco L , McConnell M , Torres T , John D , Blackwell G , Yates R , Brown C , Reyes K , McAllister GA , Kunz J , Conners EE , Benedict KM , Kirby A , Mattioli M , Xu K , Gualandi N , Booth S , Novosad S , Arduino M , Halpin AL , Wells K , Walters MS . Emerg Infect Dis 2022 28 (10) 2069-2073 During June 2017-November 2019, a total 36 patients with carbapenem-resistant Pseudomonas aeruginosa harboring Verona-integron-encoded metallo-β-lactamase were identified in a city in western Texas, USA. A faucet contaminated with the organism, identified through environmental sampling, in a specialty care room was the likely source for infection in a subset of patients. |
Water management programs are key to managing Legionella growth and spread
Curtiss E , Hils J , Kunz J . J Environ Health 2022 84 (6) 30-32 In summer 2021, several U.S. public health jurisdictions reported increases in Legionnaires' disease cases above their respective 5-year baseline averages (Michigan Department of Health & Human Services, 2021). While the Centers for Disease Control and Prevention (CDC) does not know to what extent building water systems might have contributed to these increases, periods of reduced building occupancy or building closure and low water usage can create hazards for occupants. Reopening schools, workplaces, and businesses--and more people traveling and staying in hotels--can elevate the risk of exposure to Legionella bacteria if appropriate steps are not taken. Environmental health professionals have an important role in reminding building owners, building operators, and cooling tower operators of ways to safely reopen buildings to prevent the growth of Legionella. | |
Potential Association of Legionnaires' Disease with Hot Spring Water, Hot Springs National Park and Hot Springs, Arkansas, USA, 2018-2019
James AE , Kesteloot K , Paul JT , McMullen RL , Louie S , Waters C , Dillaha J , Tumlison J , Haselow DT , Smith JC , Lee S , Ritter T , Lucas C , Kunz J , Miller LA , Said MA . Emerg Infect Dis 2022 28 (1) 44-50 Legionella pneumophila is the cause of Legionnaires' disease, a life-threatening pneumonia that occurs after inhalation of aerosolized water containing the bacteria. Legionella growth occurs in stagnant, warm-to-hot water (77°F-113°F) that is inadequately disinfected. Piped hot spring water in Hot Springs National Park, Arkansas, USA, has naturally high temperatures (>135°F) that prevent Legionella growth, and Legionnaires' disease has not previously been associated with the park or other hot springs in the United States. During 2018-2019, Legionnaires' disease occurred in 5 persons after they visited the park; 3 of these persons were potentially exposed in spa facilities that used untreated hot spring water. Environmental testing revealed Legionella bacteria in piped spring water, including 134°F stagnant pipe water. These fi ndings underscore the importance of water management programs to reduce Legionella growth in plumbing through control activities such as maintaining hot water temperatures, reducing stored water age, and ensuring adequate water flow. © 2022 Centers for Disease Control and Prevention (CDC). All rights reserved. |
Preventing Legionnaires disease: Frontline tools for environmental health practitioners
Clopper B , Kunz J , Hannapel E . J Environ Health 2021 83 (8) 32-35 Environmental health practitioners play a critical role in the prevention, identification, and mitigation of Legionnaires' disease outbreaks. Over the last 20 years, Legionnaires' disease outbreaks have increased significantly and the Centers for Disease Control and Prevention (CDC) continues to learn about the disease and how to prevent it. For example, CDC investigations show almost all (9 in 10) Legionnaires' disease outbreaks were caused by problems preventable with more effective building water management. Water management programs have become an important industry standard and are now required in healthcare facilities nationwide. | | This month's column highlights updated and new resources for preventing Legionnaires' disease for environmental health practitioners. These tools include updated guidance on preventing Legionella in water systems and devices, a new toolkit for controlling Legionella in common sources of exposure, and an updated Legionella Environmental Health Assessment Form for building water systems. |
Communicating effectively to overcome misinformation
Khan A , Dove T , Segerlind S . J Environ Health 2021 83 (6) 44-46 Editor's Note: The National Environmental Health Association strives to provide up-to-date and relevant information on environmental health and to build partnerships in the profession. In pursuit of these goals, we feature a column on environmental health services from the Centers for Disease Control and Prevention (CDC) in every issue of the Journal. | | In these columns, authors from CDC's Water, Food, and Environmental Health Services Branch, as well as guest authors, will share insights and information about environmental health programs, trends, issues, and resources. The conclusions of these columns are those of the author(s) and do not necessarily represent the official position of CDC. | | Water Management Programs Are Key to Managing Legionella Growth and Spread | Elaine Curtiss, MEd, National Center for Environmental Health, Centers for Disease Control and Prevention | Janie Hils, MPH, National Center for Environmental Health, Centers for Disease Control and Prevention | CDR Jasen Kunz, MPH, REHS/RS, National Center for Environmental Health, Centers for Disease Control and Prevention | In summer 2021, several U.S. public health jurisdictions reported increases in Legionnaires' disease cases above their respective 5-year baseline averages. While the Centers for Disease Control and Prevention (CDC) does not know to what extent building water systems might have contributed to these increases, periods of reduced building occupancy or building closure and low water usage can create hazards for occupants. Reopening schools, workplaces, and businesses—and more people traveling and staying in hotels—can elevate the risk of exposure to Legionella bacteria if appropriate steps are not taken. Environmental health professionals have an important role in reminding building owners, building operators, and cooling tower operators of ways to safely reopen buildings to prevent the growth of Legionella. | | Water management programs help people identify hazardous conditions and take steps to minimize the growth and spread of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multistep process that requires continuous review. This month's column provides several different resources from CDC to aid in the development of water management programs and prevent the spread and growth of Legionella. |
A methodology for classifying root causes of outbreaks of Legionnaires' disease: Deficiencies in environmental control and water management
Clopper BR , Kunz JM , Salandy SW , Smith JC , Hubbard BC , Sarisky JP . Microorganisms 2021 9 (1) 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. |
Safe Use and Storage of Cleaners, Disinfectants, and Hand Sanitizers: Knowledge, Attitudes, and Practices among U.S. Adults during the COVID-19 Pandemic, May 2020.
Gharpure R , Miller GF , Hunter CM , Schnall AH , Kunz J , Garcia-Williams AG . Am J Trop Med Hyg 2020 104 (2) 496-501 Cleaning and disinfection of frequently touched surfaces and frequent hand hygiene are recommended measures to prevent transmission of SARS-CoV-2, the virus that causes COVID-19. Since the onset of the COVID-19 pandemic, poison center calls regarding exposures to cleaners, disinfectants, and hand sanitizers have increased as compared with prior years, indicating a need to evaluate household safety precautions. An opt-in Internet panel survey of 502 U.S. adults was conducted in May 2020. Survey items evaluated knowledge regarding use and storage of cleaners, disinfectants, and hand sanitizers; attitudes about household cleaning and disinfection; and safety precautions practiced during the prior month. We assigned a knowledge score to each respondent to quantify knowledge of safety precautions and calculated median scores by demographic characteristics and attitudes. We identified gaps in knowledge regarding safe use and storage of cleaners, disinfectants, and hand sanitizers; the overall median knowledge score was 5.17 (95% CI: 4.85-5.50; maximum 9.00). Knowledge scores were lower among younger than older age-groups and among black non-Hispanic and Hispanic respondents compared with white non-Hispanic respondents. A greater proportion of respondents expressed knowledge of safety precautions than the proportion who engaged in these precautions. Tailored communication strategies should be used to reach populations with lower knowledge of cleaning and disinfection safety. In addition, as knowledge alone did not shape individual engagement in safety precautions, health promotion campaigns may specifically emphasize the health risks of unsafe use and storage of cleaners, disinfectants, and hand sanitizers to address risk perception. |
Knowledge and Practices Regarding Safe Household Cleaning and Disinfection for COVID-19 Prevention - United States, May 2020.
Gharpure R , Hunter CM , Schnall AH , Barrett CE , Kirby AE , Kunz J , Berling K , Mercante JW , Murphy JL , Garcia-Williams AG . MMWR Morb Mortal Wkly Rep 2020 69 (23) 705-709 A recent report described a sharp increase in calls to poison centers related to exposures to cleaners and disinfectants since the onset of the coronavirus disease 2019 (COVID-19) pandemic (1). However, data describing cleaning and disinfection practices within household settings in the United States are limited, particularly concerning those practices intended to prevent transmission of SARS-CoV-2, the virus that causes COVID-19. To provide contextual and behavioral insight into the reported increase in poison center calls and to inform timely and relevant prevention strategies, an opt-in Internet panel survey of 502 U.S. adults was conducted in May 2020 to characterize knowledge and practices regarding household cleaning and disinfection during the COVID-19 pandemic. Knowledge gaps were identified in several areas, including safe preparation of cleaning and disinfectant solutions, use of recommended personal protective equipment when using cleaners and disinfectants, and safe storage of hand sanitizers, cleaners, and disinfectants. Thirty-nine percent of respondents reported engaging in nonrecommended high-risk practices with the intent of preventing SARS-CoV-2 transmission, such as washing food products with bleach, applying household cleaning or disinfectant products to bare skin, and intentionally inhaling or ingesting these products. Respondents who engaged in high-risk practices more frequently reported an adverse health effect that they believed was a result of using cleaners or disinfectants than did those who did not report engaging in these practices. Public messaging should continue to emphasize evidence-based, safe practices such as hand hygiene and recommended cleaning and disinfection of high-touch surfaces to prevent transmission of SARS-CoV-2 in household settings (2). Messaging should also emphasize avoidance of high-risk practices such as unsafe preparation of cleaning and disinfectant solutions, use of bleach on food products, application of household cleaning and disinfectant products to skin, and inhalation or ingestion of cleaners and disinfectants. |
Legionnaires disease at a hotel in Missouri, 2015: The importance of environmental health expertise in understanding water systems
Ahmed SS , Hunter CM , Mercante JW , Garrison LE , Turabelidze G , Kunz J , Cooley LA . J Environ Health 2019 81 (7) 8-13 During a Legionnaires disease outbreak at a Missouri hotel in 2015, the Centers for Disease Control and Prevention assisted state and local health departments to identify possible sources and transmission factors and to recommend improvements to water management. We performed an environmental assessment to understand the hotels water systems and identify areas of risk for Legionella amplifi cation and transmission. We obtained samples from the pool, spa, and potable water systems for Legionella culture. In the potable water system, we noted temperatures ideal for Legionella amplifi cation and areas of water stagnation. Additionally, we found inadequate documentation of pool and spa disinfection and maintenance. Of 40 water samples, Legionella pneumophila serogroup 1 that matched the sequence type of one available clinical isolate was recovered from five sink and shower fixtures. A comprehensive environmental assessment proved crucial to identifying maintenance issues in the hotels water systems and underscored the need for a water management program to reduce Legionnaires disease risk. |
Advancing public health department legionnaires' disease prevention efforts through the epidemiology and laboratory capacity for infectious diseases cooperative agreement
Hunter C , Cooley L , Kunz J . J Environ Health 2018 81 (1) 30-33 Legionnaires' disease (LD) is a severe respiratory illness caused by breathing in aerosolized water containing Legionella bacteria. Legionella-related outbreaks account for almost 60% of reported potable water outbreaks. The number of reported LD cases has increased 350% since 2000. The reason for this increase is unknown but is likely multifactorial and due to increased susceptible populations, opportunities for Legionella growth in the environment, or awareness with improved testing and reporting. | | Based on the association of Legionella with water in built environments, implementation of effective water management programs (WMPs) has been cited as an important LD prevention measure, Health departments might not have the environmental expertise or resources, however, to provide WMP guidance. Anticipating the need for WMP expertise, the Centers for Disease Control and Prevention's National Center for Environmental Health and National Center for Immunization and Respiratory Diseases LD team has funded state and local health agencies in 2016 through the Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement to build capacity for LD response and prevention. This month's column explores the goals and work being done through this funding. |
Outbreaks associated with treated recreational water - United States, 2000-2014
Hlavsa MC , Cikesh BL , Roberts VA , Kahler AM , Vigar M , Hilborn ED , Wade TJ , Roellig DM , Murphy JL , Xiao L , Yates KM , Kunz JM , Arduino MJ , Reddy SC , Fullerton KE , Cooley LA , Beach MJ , Hill VR , Yoder JS . MMWR Morb Mortal Wkly Rep 2018 67 (19) 547-551 Outbreaks associated with exposure to treated recreational water can be caused by pathogens or chemicals in venues such as pools, hot tubs/spas, and interactive water play venues (i.e., water playgrounds). During 2000-2014, public health officials from 46 states and Puerto Rico reported 493 outbreaks associated with treated recreational water. These outbreaks resulted in at least 27,219 cases and eight deaths. Among the 363 outbreaks with a confirmed infectious etiology, 212 (58%) were caused by Cryptosporidium (which causes predominantly gastrointestinal illness), 57 (16%) by Legionella (which causes Legionnaires' disease, a severe pneumonia, and Pontiac fever, a milder illness with flu-like symptoms), and 47 (13%) by Pseudomonas (which causes folliculitis ["hot tub rash"] and otitis externa ["swimmers' ear"]). Investigations of the 363 outbreaks identified 24,453 cases; 21,766 (89%) were caused by Cryptosporidium, 920 (4%) by Pseudomonas, and 624 (3%) by Legionella. At least six of the eight reported deaths occurred in persons affected by outbreaks caused by Legionella. Hotels were the leading setting, associated with 157 (32%) of the 493 outbreaks. Overall, the outbreaks had a bimodal temporal distribution: 275 (56%) outbreaks started during June-August and 46 (9%) in March. Assessment of trends in the annual counts of outbreaks caused by Cryptosporidium, Legionella, or Pseudomonas indicate mixed progress in preventing transmission. Pathogens able to evade chlorine inactivation have become leading outbreak etiologies. The consequent outbreak and case counts and mortality underscore the utility of CDC's Model Aquatic Health Code (https://www.cdc.gov/mahc) to prevent outbreaks associated with treated recreational water. |
Reducing Legionnaires' disease in public spas
Hunter CM , Laco J , Kunz J . ASHRAE J 2017 59 (12) 56-58 Data from the Centers for Disease Control and Prevention (CDC) shows improper maintenance of public spas increases risk for Legionnaires' disease. Legionnaires' disease affects thousands of individuals each year and represents a significant public health burden, with a 10% case fatality rate and an estimated annual hospitalization cost burden of $433 million.1,2 CDC's Model Aquatic Health Code (MAHC) offers critical guidance for reducing the risk of Legionnaires' disease in public aquatic facilities. |
Vital Signs: Health care-associated Legionnaires' disease surveillance data from 20 states and a large metropolitan area - United States, 2015
Soda EA , Barskey AE , Shah PP , Schrag S , Whitney CG , Arduino MJ , Reddy SC , Kunz JM , Hunter CM , Raphael BH , Cooley LA . MMWR Morb Mortal Wkly Rep 2017 66 (22) 584-589 BACKGROUND: Legionnaires' disease, a severe pneumonia, is typically acquired through inhalation of aerosolized water containing Legionella bacteria. Legionella can grow in the complex water systems of buildings, including health care facilities. Effective water management programs could prevent the growth of Legionella in building water systems. METHODS: Using national surveillance data, Legionnaires' disease cases were characterized from the 21 jurisdictions (20 U.S. states and one large metropolitan area) that reported exposure information for ≥90% of 2015 Legionella infections. An assessment of whether cases were health care-associated was completed; definite health care association was defined as hospitalization or long-term care facility residence for the entire 10 days preceding symptom onset, and possible association was defined as any exposure to a health care facility for a portion of the 10 days preceding symptom onset. All other Legionnaires' disease cases were considered unrelated to health care. RESULTS: A total of 2,809 confirmed Legionnaires' disease cases were reported from the 21 jurisdictions, including 85 (3%) definite and 468 (17%) possible health care-associated cases. Among the 21 jurisdictions, 16 (76%) reported 1-21 definite health care-associated cases per jurisdiction. Among definite health care-associated cases, the majority (75, 88%) occurred in persons aged ≥60 years, and exposures occurred at 72 facilities (15 hospitals and 57 long-term care facilities). The case fatality rate was 25% for definite and 10% for possible health care-associated Legionnaires' disease. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Exposure to Legionella from health care facility water systems can result in Legionnaires' disease. The high case fatality rate of health care-associated Legionnaires' disease highlights the importance of case prevention and response activities, including implementation of effective water management programs and timely case identification. |
Legionnaires' outbreaks preventable with water management programs
Lucas CE , Cooley LA , Kunz JM , Garrison LE . ASHRAE J 2016 58 (11) 84-86 The first documented outbreak of Legionnaires' disease was investigated by the Centers for Disease Control and Prevention (CDC) in 1976. Researchers of the time identified a novel bacterial agent responsible for causing the severe pneumonia that sickened or killed several of the American Legionnaires who attended a convention in Pennsylvania. In the ensuing years, scientists characterized the newly discovered bacterium, called Legionella in tribute to the first known victims. Since then we have discovered where the bacteria live, how they cause disease, and the ways they can be transmitted to humans. Most importantly, we learned that most of the disease caused by Legionella is preventable. |
Vital Signs: Deficiencies in environmental control identified in outbreaks of Legionnaires' Disease - North America, 2000-2014
Garrison LE , Kunz JM , Cooley LA , Moore MR , Lucas C , Schrag S , Sarisky J , Whitney CG . MMWR Morb Mortal Wkly Rep 2016 65 (22) 576-584 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. |
Immediate closures and violations identified during routine inspections of public aquatic facilities - Network for Aquatic Facility Inspection Surveillance, five states, 2013
Hlavsa MC , Gerth TR , Collier SA , Dunbar EL , Rao G , Epperson G , Bramlett B , Ludwig DF , Gomez D , Stansbury MM , Miller F , Warren J , Nichol J , Bowman H , Huynh BA , Loewe KM , Vincent B , Tarrier AL , Shay T , Wright R , Brown AC , Kunz JM , Fullerton KE , Cope JR , Beach MJ . MMWR Surveill Summ 2016 65 (5) 1-26 PROBLEM/CONDITION: Aquatic facility-associated illness and injury in the United States include disease outbreaks of infectious or chemical etiology, drowning, and pool chemical-associated health events (e.g., respiratory distress or burns). These conditions affect persons of all ages, particularly young children, and can lead to disability or even death. A total of 650 aquatic facility-associated outbreaks have been reported to CDC for 1978-2012. During 1999-2010, drownings resulted in approximately 4,000 deaths each year in the United States. Drowning is the leading cause of injury deaths in children aged 1-4 years, and approximately half of fatal drownings in this age group occur in swimming pools. During 2003-2012, pool chemical-associated health events resulted in an estimated 3,000-5,000 visits to U.S. emergency departments each year, and approximately half of the patients were aged <18 years. In August 2014, CDC released the Model Aquatic Health Code (MAHC), national guidance that can be adopted voluntarily by state and local jurisdictions to minimize the risk for illness and injury at public aquatic facilities. REPORTING PERIOD COVERED: 2013. DESCRIPTION OF SYSTEM: The Network for Aquatic Facility Inspection Surveillance (NAFIS) was established by CDC in 2013. NAFIS receives aquatic facility inspection data collected by environmental health practitioners when assessing the operation and maintenance of public aquatic facilities. This report presents inspection data that were reported by 16 public health agencies in five states (Arizona, California, Florida, New York, and Texas) and focuses on 15 MAHC elements deemed critical to minimizing the risk for illness and injury associated with aquatic facilities (e.g., disinfection to prevent transmission of infectious pathogens, safety equipment to rescue distressed bathers, and pool chemical safety). Although these data (the first and most recent that are available) are not nationally representative, 15.7% of the estimated 309,000 U.S. public aquatic venues are located in the 16 reporting jurisdictions. RESULTS: During 2013, environmental health practitioners in the 16 reporting NAFIS jurisdictions conducted 84,187 routine inspections of 48,632 public aquatic venues. Of the 84,187 routine inspection records for individual aquatic venues, 78.5% (66,098) included data on immediate closure; 12.3% (8,118) of routine inspections resulted in immediate closure because of at least one identified violation that represented a serious threat to public health. Disinfectant concentration violations were identified during 11.9% (7,662/64,580) of routine inspections, representing risk for aquatic facility-associated outbreaks of infectious etiology. Safety equipment violations were identified during 12.7% (7,845/61,648) of routine inspections, representing risk for drowning. Pool chemical safety violations were identified during 4.6% (471/10,264) of routine inspections, representing risk for pool chemical-associated health events. INTERPRETATION: Routine inspections frequently resulted in immediate closure and identified violations of inspection items corresponding to 15 MAHC elements critical to protecting public health, highlighting the need to improve operation and maintenance of U.S. public aquatic facilities. These findings also underscore the public health function that code enforcement, conducted by environmental health practitioners, has in preventing illness and injury at public aquatic facilities. PUBLIC HEALTH ACTION: Findings from the routine analyses of aquatic facility inspection data can inform program planning, implementation, and evaluation. At the state and local level, these inspection data can be used to identify aquatic facilities and venues in need of more frequent inspections and to select topics to cover in training for aquatic facility operators. At the national level, these data can be used to evaluate whether the adoption of MAHC elements minimizes the risk for aquatic facility-associated illness and injury. These findings also can be used to prioritize revisions or updates to the MAHC. To optimize the collection and analysis of aquatic facility inspection data and thus application of findings, environmental health practitioners and epidemiologists need to collaborate extensively to identify public aquatic facility code elements deemed critical to protecting public health and determine the best way to assess and document compliance during inspections. |
A molecular sensor to characterize arenavirus envelope glycoprotein cleavage by subtilisin kexin isozyme-1 (SKI-1)/site-1 protease (S1P).
Oppliger J , da Palma JR , Burri DJ , Bergeron E , Khatib AM , Spiropoulou CF , Pasquato A , Kunz S . J Virol 2015 90 (2) 705-14 Arenaviruses are emerging viruses including several causative agents of severe hemorrhagic fevers in humans. The advent of next-generation sequencing technology has greatly accelerated the discovery of novel arenavirus species. However, for many of these viruses only genetic information is available and their zoonotic disease potential remains unknown. During the arenavirus life cycle, processing of the viral envelope glycoprotein precursor (GPC) by the cellular subtilisin kexin isozyme-1 (SKI-1)/site-1 protease (S1P) is crucial for productive infection. The ability of newly emerging arenaviruses to hijack human SKI-1/S1P appears therefore as a requirement for efficient zoonotic transmission and human disease potential. Here we implement a newly developed cell-based molecular sensor for SKI-1/S1P to characterize the processing of arenavirus GPC-derived target sequences by human SKI-1/S1P in a quantitative manner. We show that only nine amino acids flanking the putative cleavage site are necessary and sufficient to accurately recapitulate efficiency and subcellular location of arenavirus GPC processing. In proof-of-concept, our sensor correctly predicts efficient processing of the GPC of the newly emerged pathogenic Lujo virus by human SKI-1/S1P and defines the exact cleavage site. Lastly, we employed our sensor to show efficient GPC processing of a panel of pathogenic and non-pathogenic New World arenaviruses, suggesting that GPC cleavage represents no barrier for zoonotic transmission of these pathogens. Our SKI-1/S1P sensor thus represents a rapid and robust test system to assess processing of putative cleavage sites derived from newly discovered arenavirus GPC by SKI-1/S1P of humans or any other species, based solely on sequence information. IMPORTANCE: Arenaviruses are important emerging human pathogens that can cause severe hemorrhagic fevers with high m-+ortality in humans. A crucial step in productive infection of arenaviruses in human cells is processing of the viral envelope glycoprotein by the cellular subtilisin kexin isozyme-1 (SKI-1)/site-1 protease (S1P). In order to break the species barrier during zoonotic transmission and to cause severe disease in man, newly emerging arenaviruses must be able to efficiently hijack human SKI-1/S1P. Here we implement a newly developed cell-based molecular sensor for human SKI-1/S1P to characterize the processing of arenavirus glycoproteins in a quantitative manner. We further use our sensor to correctly predict efficient processing of the glycoprotein of the newly emerged pathogenic Lujo virus by human SKI-1/S1P. Our sensor represents thus a rapid and robust test system to assess if the glycoprotein of any newly emerging arenavirus can be efficiently processed by human SKI-1/S1P, based solely on sequence information. |
It's all about the return on investment: the Model Aquatic Health Code
Hlavsa MC , Kunz JM , Beach MJ . J Environ Health 2015 77 (9) 34-35 In 2005, local, state, and federal public health officials and representatives from the aquatic sector met in Atlanta to discuss and develop a strategy to tackle the increasing incidence of recreational water-associated outbreaks, particularly cryptosporidiosis outbreaks associated with public pools. Public health and the aquatics sector quickly reached consensus. They identified the lack of uniform national standards for the design, construction, operation, and maintenance of public pools as the key barrier to preventing outbreaks and called on the Centers for Disease Control and Prevention (CDC) to lead development of national guidance. For the next seven years, CDC and New York State Department of Health spearheaded a national, multi-partner effort to create the Model Aquatic Health Code (MAHC; www. cdc.gov/healthywater/swimming/pools/mahc/ index.html). In August 2014, the first edition of the MAHC was released. This 316page resource is based on the latest science and best practices to maximize prevention of recreational water-associated outbreaks, pool chemical-associated health events, and drowning. The accompanying 371-page annex provides the rationale behind the guidance. The MAHC and its annex represent the culmination of the hard work of more than 150 public health, aquatic sector, and academic volunteers and their response to 4,407 public comments, of which 72% were accepted. So where do we go from here? Together, we need to set up systems to assess the MAHC's ROI and use system data to maximize the MAHC's ability to provide long-term public health dividends. |
The first edition of the Model Aquatic Health Code is now available: what's next?
Kunz J , Beach M . J Environ Health 2014 77 (5) 34-6 The first edition of the Model Aquatic Health Code (MAHC) was released on August 29, 2014, and is now available on the Centers for Disease Control and Prevention’s (CDC’s) Web site (www.cdc.gov/mahc, see Figure 1). The MAHC is a set of free guidelines based on science and best practices to help jurisdictions reduce outbreaks, drowning, and chemical injuries at public aquatic facilities. The MAHC is a model—not a federal law—that local and state agencies can use to update or implement aquatic facility codes, rules, regulations, guidance, laws, or standards. The MAHC is inclusive; it covers all health and safety issues by providing sample code language and explanatory text addressing design and construction, operation and maintenance, and policies and management. The MAHC is voluntary; jurisdictions can use some, all, or none of the MAHC, and they can change any part of it to suit their needs (see Figure 2). |
Putting theory into practice--CDC's Summer Program in Environmental Health (SUPEH)
Gerding J , Kunz J . J Environ Health 2011 73 (6) 96-8 The Centers for Disease Control and | Prevention’s (CDC’s) environmental health internship is an educational experience exposing students to a | field that requires diverse competencies in | areas that range from sampling and conducting investigations to critical thinking | and effective communication. These competencies are partially identified by NEHA, | which lists 15 technical content areas in | which the registered environmental health | specialist (REHS) should be proficient (see | sidebar on page 97). In addition to these | technical competencies, 14 core competencies for environmental health practitioners have been identified by an expert | panel convened by the American Public | Health Association (APHA) and CDC (see | sidebar on page 98). Diverse competency | requirements reinforce the importance of | exposing environmental health interns to | the many aspects of the profession, both | technical and professional. |
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