New Mexico Waterborne Disease Surveillance Project Annual ...

New Mexico Waterborne Disease Surveillance Project

Annual Report 2002

Prepared by Karen Johnson Environmental Health Epidemiology Unit

JPA # 00/667/JPA/012 July 2003

1

NEW MEXICO WATERBORNE DISEASE SURVEILLANCE PROJECT ANNUAL REPORT, 2002

INTRODUCTION......................................................................................................................................................3 PURPOSE .............................................................................................................................................................3

METHODS ..................................................................................................................................................................3

RESULTS......................................................................................................................................................................4 CALLS .................................................................................................................................................................4

Figure 1. Water-related Calls by Type, New Mexico, 2002 ...........................................................................5 CHEMICAL MAXIMUM CONTAMINANT LEVEL (MCL) VIOLATIONS....................................................................5

Figure 2. Percent of Water Systems with a Nitrate Violation (by County), New Mexico, 2001 - 2002..........6 BIOLOGICAL CONTAMINATION OF WATER SYSTEMS ..........................................................................................7

Figure 3. Map of Water Advisories by County, New Mexico, 2002 ...............................................................8 CASES OF POTENTIAL WATERBORNE DISEASE......................................................................................................8

Table 1. Percentage of Selected Diseases Estimated to be Foodborne, New Mexico, 2002 ..........................9 Figure 4. Percentage of reported illnesses estimated to be due to water, sanitation, and hygiene, NM, 2001-2002.......................................................................................................................................................9 Table 2. Selected Disease Rates* in New Mexico (2002) and the US (2001)...............................................10

CASE STUDY: A POTENTIAL WATERBORNE DISEASE CLUSTER IN A SMALL SUBDIVISION ..................................14 OTHER WDSP OUTCOMES................................................................................................................................16

DISCUSSION ...........................................................................................................................................................16

CONCLUSION.........................................................................................................................................................17 RECOMMENDATIONS .........................................................................................................................................17

REFERENCES ..........................................................................................................................................................18 APPENDICES ......................................................................................................................................................18

APPENDIX 1, DISEASE SPECIFIC CHARTS AND MAPS .........................................................................19 DEFINITION OF TERMS: .....................................................................................................................................20

APPENDIX 2, FACT SHEETS & PRESENTATIONS....................................................................................40

___________________________________________________________ Waterborne Disease Surveillance Project Annual Report, 2002

2

INTRODUCTION Purpose In April 2000, the New Mexico Environment Department (NMED) funded the New Mexico Department of Health (NMDOH), Office of Epidemiology to develop a waterborne disease surveillance system in an effort to evaluate NMED efforts towards ensuring safe drinking water in New Mexico. The purpose of the waterborne disease surveillance project (WDSP) was to develop a system for identifying incidents and outbreaks of waterborne disease in New Mexico and to maintain a database of waterborne disease events. Based on an extensive literature review, seven disease-causing infectious agents were included in the initial surveillance efforts. The organisms include three parasitic agents (Entamoeba histolytica, Cryptosporidium sp., Giardia sp.), three bacterial agents (Campylobacter sp., enterohemorrhagic Escherichia coli, and Shigella sp.), and one viral agent (Hepatitis A). All of the identified diseases are “notifiable conditions”; reportable by law to NMDOH. This report encompasses year two of the WDSP (2002). Year 2002 program changes reflected recommendations noted in the Year 2001 annual report. Weekly monitoring of reported cases of each disease was deemed a priority. The Environmental Health Epidemiology Unit (EHEU) worked closely with the Infectious Disease Unit to follow up cases. In addition, the EHEU took on the responsibility of systematically taking public calls for environmental health issues. Systematic collaboration continued with NMED’s Drinking Water Bureau (DWB). METHODS Information to track the burden of waterborne disease was collected through a number of different sources. Call tracking, communication between agencies, test results from the state scientific laboratory and NMED, and the infectious disease database (National Electronic Telecommunications System for Surveillance - NETSS) were all mechanisms used to track potential and actual exposures and disease in New Mexico. Water quality data were compared with disease reports and calls to identify any suspected waterborne disease cases. A contact database was developed early in the project to track calls received by the Environmental Health Epidemiology Unit (EHEU). Caller type, location, major/minor call topics, and other specific information are some variables collected in the database. During October 2002, the decision was made to assign one member of the EHEU to take all environmental health calls on a given day. A calendar was produced and provided to the administrative staff who initially receive the calls and to the infectious disease epidemiology staff who systematically take call. In this manner, calls which in the past would have been responded to by the infectious disease epidemiology staff could be referred to a single point of contact in the EHEU.


3

The communication protocol developed during the initial stages of the JPA between NMED Drinking Water Bureau and the EHEU identifying a single point of contact (with a designated back-up) in each agency was reviewed and updated as needed (see Appendix 2). Via this process, NMED relays information regarding water system violations or refers concerned members of the public to EHEU. New Mexico public water systems are reqinorganic chemicals (non-transient, non-csynthetic organic contaminants and twenRadionuclide levels (alpha, beta, radium-another radionuclide, Uranium, will be moaddition, community water systems that sindividuals and add a disinfectant to any trihalomethanes (20 NMAC 7.1). ResultsDWB. NMDOH and NMED are working oeducation and information on any of thesMCL in New Mexico. Surveillance for reportable diseases is onare reported to the Office of EpidemiologState surveillance staff inform the local pa reportable disease case; local public hereport form to document the investigationcollected by the local health office are sureported through the National Electronic Surveillance (NETSS) to the Centers for When necessary, the EHEU is called upoUnit for assistance with possible waterboAssistance takes the form of follow-up terelaying information to and from NMED. RESULTS Calls The EHEU received 47 water-related call“Incident Database”; a 52% increase in th2001. Part of this increase may be due toOctober 2002 to take environmental healdisease epidemiologist on call handled m

_______________________________________Waterborne Disease Surveillance Project Ann

Types of Public Water Systems: Community water system: serves at least 15 service connections used by year-round residents or regularly serves at least 25 year-round residents. Non-transient non-community water system: serves at least 25 persons for more than 6 months per year, including but not limited to schools and factories. Non-community water system: serves 25 or more persons who are not residents year-round(e.g. restaurants, rest areas, gas stations) or seasonal facilities (e.g. children’s camps or recreational campin

g facilities). Definitions: 20 NMAC 7.1.

uired by law to monitor for sixteen ommunity systems monitor fourteen), thirty ty-one volatile organic contaminants. 226 and radium–228) are also monitored; nitored beginning in December 2003. In erve a population of 10,000 or more part of the water system must monitor for of these analyses are reported the NMED’s n ways to collaborate to provide public e chemicals that consistently exceed the

going in the state of New Mexico. Diseases y by laboratories or health care providers. ublic health office when they are alerted to alth nurses use a standard enteric disease of enteric disease cases. Surveillance data bmitted to the Office of Epidemiology and Telecommunications System for Disease Control and Prevention (CDC). n by the Infectious Disease Epidemiology rne disease-related illness reports. lephone calls, information gathering, and

s in 2002 that were recorded in the e number of water-related calls recorded in the system developed by EHEU in th-related calls. Prior to this, the infectious any environmental health-related calls. The

____________________ ual Report, 2002

4

majority of the calls in 2002 (41%) were from the general public, followed by referrals from the DWB (32%). The remaining calls were from other NMED bureaus, district public health staff, the media, physicians, and a school principal. Figure one shows calls by caller type during 2002. Figure 1. Water-related Calls by Type, New Mexico, 2002

Water-related Calls by Caller TypeNew Mexico, 2002

Total Calls=47

State Agency (NMED DWB)32%

Other DOH13%

Media4%

State Agency (NMED, other)

6%

Other2%

Physician2%

General Public41%

Chemical Maximum Contaminant Level (MCL) Violations Nitrate is an inorganic chemical that can have some serious health effects in certain populations. This chemical was chosen for analysis because many of New Mexico’s water systems have a history of violating the Nitrate MCL, suggesting the potential for adverse health effects. A syndrome called methemoglobinemia occurs when the ingested nitrate interferes with the ability for blood to carry oxygen to the body tissues, which need a constant supply of oxygen to survive. This is a particular problem in infants, pregnant women, or the elderly, because of body chemistry. An analysis of the NMED DWB’s database indicated that during 2001 to 2002, 11 of the 33 counties had one or more public water systems that violated the MCL for nitrate. Figure 2 illustrates which counties have the highest percentage of water systems with nitrate violations during the 2-year period. The county with the highest percentage of water systems violating the MCL was Lea County in southeastern New Mexico. The southeastern portion of the state in general was most affected by


5

nitrate contamination, possibly due to dairy farming or other agricultural activities. Strategies for providing public information to affected counties will continue into 2003 and will be reported in the next annual report. There were, however, no reported cases of methemoglobinemia in 2002. During the next year, NMDOH will work with NMED to identify other chemical contaminants in public water systems that may result in adverse health effects in New Mexico. Figure 2. Percent of Water Systems with a Nitrate Violation (by County), New Mexico, 2001 - 2002


6

Biological Contamination of Water Systems Drinking water systems are sampled on a routine basis for total coliforms (TCs) to assure compliance with federal drinking water standards. Total coliforms are a group of bacterial organisms that are present in the natural environment. If a water system tests positive for TC, further testing is done for fecal coliform (FC) or for E. coli, one of the fecal coliform organisms. FCs are organisms that are present in intestinal systems of all warm-blooded animals; most are not dangerous to humans, however, some may cause adverse health effects. Fecal coliforms are also used as an indicator organism. Because fecal coliforms occur naturally in animal intestines, contamination may indicate that other disease-causing organisms spread through feces (bacteria, parasites, and viruses) could be present in the water. When fecal contamination is identified in a system, confirmatory samples are taken immediately to rule out sampling or other errors. If the confirmatory samples show fecal contamination, NMED issues an acute violation and confers with NMDOH to decide whether to issue a “Boil Water Advisory”. A situation in which an advisory might not be issued is when the water source is not being used as drinking water. Upon issuance, NMDOH notifies district public health offices to be on alert for cases of gastrointestinal illness. Water system consumers are notified by the water system through an interagency press release or individual notification. There were 10 Boil Water Advisories in 2002. Figure 4 shows the distribution of advisories throughout the state. One advisory, issued in February 2001, was still in effect as of December 2002.


7

Figure 3. Map of Water Advisories by County, New Mexico, 2002

Rio Arriba

San Miguel

Guadalupe

Chaves

EddyOteroDona Ana

Bernalillo

Valencia

Water System Advisories by CountyNew Mexico, 2002

Cases of potential waterborne disease There were no confirmed disease incidents related to public water systems in 2002; however, data were collected on potential waterborne disease events to ensure that no waterborne outbreaks were missed. Absolute confirmation of disease etiology is difficult, as it involves a timely stool sample and water sample, and a laboratory comparison of organisms identified in each. Often, diseases are not reported to the Office of Epidemiology until many days or weeks after symptom onset, which makes sample collection problematic. There were 815 reported cases of the selected potential waterborne diseases, approximately 100 more than in 2001. Based on estimates by the US Centers for Disease Control & Prevention, nearly half of those


8

are probably foodborne (Mead et al, 2000). Table 1 indicates the counts of each disease that are likely to be foodborne. Because the actual foodborne cases could not be separated from the others, all reported cases of the selected diseases were used in the analysis. Table 1. Percentage of Selected Diseases Estimated to be Foodborne, New Mexico, 2002 Disease

2002 Reported NM Cases

% Estimated to be waterborne

or other**

% Estimated to be Foodborne*

Estimated # waterborne or

other etiology** Amebiasis 8 Unknown Unknown 8 Campylobacteriosis 347 20 80 69 Cryptosporidiosis 20 90 10 18 E. coli (O157:H7 & STX+) 17 15 85 2 Giardiasis 148 90 10 133 Hepatitis A 32 95Ŧ 5 30Ŧ Shigellosis 243 80Ŧ 20 196Ŧ Total 815 456 *Estimated percents from Mead, et al, (2000). Food-related illness and death in the United States, Emerging Infectious Diseases, 5 (5). **Other etiology could include person-to-person or animal-to-person ŦHepatitis A and Shigella organisms are more often spread from person-to-person than through water. Figure 4 shows a chart of illnesses reported in years 2001 and 2002 that are estimated to be related to water, sanitation and hygiene. Shigellosis represents the highest percentage, however that disease is more frequently associated with person-to-person contact than water contamination. Giardiasis, which is more commonly related to contaminated water ingestion, makes up 32% of the two-year sample. Figure 4. Percentage of reported illnesses estimated to be due to water, sanitation, and hygiene, NM, 2001-2002

Water, Sanitation, & Hygiene2001 & 2002

N=830

Amebiasis2% Campylobacteriosis

17%

Cryptosporidiosis5%

E. Coli (Shiga-toxin +)1%

Giardiasis32%

Hepatitis A8%

Shigellosis35%


9

Analysis of infectious disease NETSS data was performed for each of the selected potential waterborne diseases on a weekly basis. The weekly data were compared with an 11-year average rate. Each time the weekly rate exceeded one standard deviation above the average rate, a line listing which includes the case’s city of residence and street address was run for that week and surrounding two weeks to determine if there was any unrecognized spatial clustering of disease. Enteric disease report forms were reviewed to see if there was any evidence of waterborne transmission. The surveillance charts for each disease are included in Appendix 1. Maps were produced to analyze the spatial distribution of potential water-related disease cases throughout New Mexico. See Appendix 1 for disease-specific maps. Table 2 compares 2002 New Mexico data with 2001 US rates (the most recent data available) for the selected diseases. Table 2. Selected Disease Rates* in New Mexico (2002) and the US (2001) Disease NM Rate per 100,000

Persons US Rate per 100,000

Persons** Amebiasis 0.4 NA Campylobacteriosis 18.7 NA Cryptosporidiosis 1.1 1.3 E. coli (O157:H7 & STX+) 0.9 1.2 Giardiasis 8.0 NA Hepatitis A 1.7 3.8 Shigellosis 13.1 7.2 *Rates were calculated using US Census 2001 population estimates. **2001 US data from Summary of Notifiable Diseases – United States, 2001 MMWR Volume 50/No. 53; amebiasis and campylobacteriosis are not nationally reportable diseases. Giardiasis became nationally reportable in 2002. Trends in selected enteric diseases. Seven enteric diseases were selected for surveillance of waterborne illness. There were 815 reported cases of the selected potential waterborne diseases, however, there is no evidence that any of the cases was related to a public water system. Initial information such as gender, age, onset date, and address was collected for most cases. In addition, supplemental information was collected via the “Enteric Disease Report Form” for approximately 60% of the cases. This form included information on water supply, recreational water exposure, sewage exposure, various types of high-risk food exposure, travel history, and daycare exposure. The reported cases for all the diseases combined were distributed statewide, with the highest frequency of elevated disease rates in McKinley and Luna Counties (see map, Appendix 1). As is often the case with enteric disease, rates were highest for children under 5 years of age. Most symptom onset occurred during fall months (September, October, November) followed closely by summer (June, July, and August). Appendix 1 contains charts and maps that graphically represent case


10

characteristics and potential risk factors. Of the 443 individuals from whom additional information was collected, 63% reported eating in a restaurant in the two weeks prior to onset of symptoms. It is unknown the percentage of the general public who eat in restaurants. Travel history (previous 2 weeks) was collected for 460 of the 815 cases (60%). Of the 460 cases, 25% reported some travel. Analyses of the combined diseases are driven mainly by those diseases with the highest frequency of reporting (shigellosis and campylobacteriosis); analyses were performed for each individual disease due to the varying frequency and different risk factors for each disease. Amebiasis. Entamoeba histolytica is a parasite that causes intestinal and other symptoms. Upon infection, humans can shed the cyst form in their feces. The disease caused by infection with Entamoeba histolytica is referred to as amebiasis. Cysts can survive outside the host in water and soils. While ingestion of only one viable cyst can cause infection, not all infections are symptomatic. The incubation period for this organism is usually between two and four weeks, but can be from a few days to years. Unlike most enteric illnesses, amebiasis is rare in children under five years. Worldwide, infection rates are higher in those areas with poor sanitation (Chin, 2000). When untreated, infections may last for years. During 2002, there were only eight amebiasis cases reported in New Mexico. It is unknown how many of those were in individuals who lived in or visited a foreign country. Thirty-eight percent of cases were in children under five. Exposure information was collected on three of the eight cases. Campylobacteriosis. This bacterial disease is one of the most frequently reported causes of gastroenteritis in the US and in the world. The organism is often found in the gastrointestinal tracts of a wide range of birds (especially poultry) and animals, and can frequently be isolated from surface water (Hunter, 1997). Eating undercooked chicken or contact with farm animals are important risk factors for campylobacter infection. The incubation period (the amount of time from ingestion of the organism to symptom onset) is approximately two to five days. Campylobacter enteritis was the most frequently reported of the seven selected potential waterborne diseases in 2002. In New Mexico, there were 347 reported cases of campylobacteriosis in 2002; this is strikingly consistent with the 346 cases reported in 2001. Thirty-eight percent of cases reported onset during summer months (mostly in July and August), 29% reported onset during the fall. While this disease had a statewide distribution, disease rates were highest in De Baca, McKinley, Socorro, and Roosevelt Counties; Bernalillo (22%), McKinley (15%), and Dona Ana (10%) had the highest numbers of cases. During October 2002, 46 individual cases were reported in New Mexico; 57% of these cases were in McKinley County. On further investigation, however, actual disease onset in that county was similar to surrounding months. The elevated “cluster” was due to reporting of many older cases at the same time. Children aged 0 to 4 had the highest disease rates. Of


11

the 347 cases, additional risk factor information from the enteric report form was available on nearly half (188 cases – 54%). Cryptosporidiosis. The organism responsible for this disease is a parasite. This organism is especially resistant to chlorine disinfection, and thus is a potential problem in both surface and recreational waters and in groundwater systems that may have experienced sewage contamination or infiltration of surface water. Cryptosporidium has a variable incubation period, ranging from two to twenty-eight days, but typically it takes about a week between infection and illness. There were 20 reported cases of cryptosporidiosis in New Mexico during 2002. Unlike 2001, the case count was slightly higher for females than males (60% vs. 40%); children under one year of age had the highest rates. Fifty-five percent of the individuals experienced onset of symptoms during the summer months (June, July, August); 25% reported onset in the spring (March, April, May). Of the 20 cases, additional information was available for 15 individuals. Of those, 20% had contact with recreational water. Unlike last year, only one individual reported camping in the weeks preceding symptom onset; in 2001, 18% reported camping. Forty percent reported travel (an increase from 10% in 2001). Approximately 73% of those with additional risk factor information reported eating in a restaurant in the previous two weeks. Twenty-seven percent reported some underlying illness, possibly reflecting testing bias: providers may be more likely to test those patients who are most adversely affected by an illness, for example those with HIV/AIDS or some other disease that may suppress the immune system. Spatially, some of the highest rates were reported in Guadalupe County. As expected, the highest disease counts were in the Albuquerque metropolitan area. Long incubation periods for this organism can lead to difficulties in pinpointing risk factors. Enterohemorrhagic Escherichia coli infection. Enterohemorrhagic E. coli was first identified in 1982 and became a nationally reportable disease in 1993; the most commonly reported serotype is E. coli O157:H7. This type of E. coli produces a Shiga toxin that can cause severe damage to the lining of the intestine, and complications can result in serious kidney damage (Hemolytic Uremic Syndrome – HUS). Infection with this organism is most commonly associated with the ingestion of undercooked beef and other foods contaminated by cattle feces. However, waterborne transmission has also been documented. Contamination of a municipal water system in Walkerton, Ontario, Canada resulted in several deaths and significant illness in a small community. A report by the US Food and Drug Administration indicated that in the Pacific Northwest, E. coli O157:H7 was suspected to be second only to Salmonella as a cause of bacterial diarrhea, and mild infection was thought to be vastly under-reported (FDA, 2001). The incubation period ranges from two to eight days. There were 17 reported cases of enterohemorrhagic E. coli infection in New Mexico in 2002, 14 of which were attributable to E.coli O157:H7. Seventy-one percent were in males. Season of onset was typically fall (47%); 18% of reported cases noted


12

onset of symptoms in each of the other seasons. Highest rates were reported in the over 85-age group and the 1 to 4 year olds. Risk factor information was collected for 59% (10 cases). While this family of organisms is frequently associated with undercooked food, none of the high-risk food variables (e.g., eating undercooked meat) seemed to play a role in the New Mexico cases. In fact, only one person reported eating jerky, two individuals reported eating rare beef, two individuals reported contact with a sick animal, and two reported visiting a farm. None of the 10 cases reported drinking unpasteurized milk or cider, or eating unpasteurized cheese. Giardiasis. Giardia lamblia is a protozoa that is the most frequently identified cause of non-bacterial diarrhea in North America. It survives in the environment as a cyst, and is more resistant than most other waterborne pathogens (except Cryptosporidium) to chemical disinfection. Giardia lamblia infects a wide range of birds, amphibians, and other animals in nature, and is frequently found in surface water as a result of animal fecal contamination (especially beavers). The incubation period can be lengthy, ranging from three to twenty-five days. There were 148 reported cases of giardiasis in New Mexico in 2002. Further analysis of the 2002 giardiasis cases in New Mexico indicated that onset of most reported cases of disease occurred during the summer months, followed closely by spring. Children aged 0 to four had the highest reported rates. Fifty-three percent of the cases were female. Risk factor information was available on 93 of the 148 cases (59%). Thirteen percent of those reported swimming in some type of recreational water (i.e., swimming pool, reservoir, lake, river). Nearly 40% reported travel in the weeks preceding illness. Notably, 16% reported an underlying illness, once again suggesting testing bias for those with suppressed immune systems. Hepatitis A. Hepatitis A is a viral organism that can result in the following symptoms: fever, malaise, nausea, anorexia, and abdominal discomfort, followed by jaundice. Hepatitis A has a long incubation period (between 10-50 days, with an average of 30 days), making it difficult to determine water or foodborne etiology. The FDA estimated that in 1988, 7.3% of cases (nationally) were foodborne or waterborne, however direct contact (fecal-oral) was the most common route of infection. A targeted immunization program begun in 1996 has been instrumental in reducing morbidity due to Hepatitis A in New Mexico. Because of the long incubation period, additional food-related risk factor information was not analyzed for the 32 reported cases. Additional information, including travel and daycare contact was collected on 18 of the 32 cases. Nine of the 18 had traveled internationally; three had contact with children in daycare, however none of the cases was determined to be daycare associated. Shigellosis. Shigella sp. is a bacterium that almost exclusively infects humans (other primates may be infected), and some species can result in death. The species endemic in developed countries (S. sonnei and S. flexneri) typically produce milder symptoms (in those with adequate immune response) than Shigella dysenariae, the


13

species more common in developing countries. Shigellosis (bacillary dysentery) is mainly spread from person to person by direct contact (fecal-oral), but can occur through direct fecal contamination of water and food sources. The infectious dose is small, between 10 and 100 organisms, and the incubation period is relatively short (12 to 26 hours). Because this organism frequently causes bloody diarrhea, Mead et al. (1999) estimate that treatment is more often sought for shigellosis than other diarrheal illnesses, and is therefore more likely to be reported to health authorities. There were 243 reported cases of shigellosis in New Mexico in 2002, a nearly 100% increase from 2001. One to four year olds had the highest rates, followed by 5 to 14 year olds; fifty-four percent of the cases were in females. Spatially, the highest disease rates were in McKinley and Luna counties. During April 2002, there were 28 reported cases in McKinley County. However, further inspection of the data indicated that only 17 of those cases actually experienced onset of symptoms during April, while there were 10 cases that experienced symptom onset in March which were not reported in March. The infectious disease epidemiology unit followed up with area health offices in many of these cases. Of the 77 cases for whom additional information was available, 29% reported having a potential sewage contact, including direct contact with sewage, or a septic tank or cesspool at their residence. Daycare history was collected on 143 of the 243 cases. Of the 143 cases, 10% were determined to be daycare associated (5% of the total reported cases). Case Study: A potential waterborne disease cluster in a small subdivision In April 2002, an emergency room nurse noticed that several people from the same subdivision arrived for treatment of dehydration caused by diarrheal disease. At the same time, work was being done on the water system distribution lines in the subdivision (with a population of about 1,000 people), causing frequent water outages and dirt in the water supply lines. The Office of Epidemiology was notified by the hospital of this situation further information was sought to determine if there could be a relationship between the water system work and disease events. Contact with the water system operator revealed that there were two accidental water distribution line breaks during the construction process. Methods: The initial case definition was symptoms of diarrhea or vomiting between April 9th and 22nd. The infectious disease epidemiology unit surveillance nurse collected contact information for those appearing at the emergency room and followed up to collect names and addresses of other individuals experiencing symptoms. Symptomatic individuals (13 of the approximately 1,000 subdivision residents) were encouraged to produce a stool sample for analysis. Two stool samples were obtained and sent to the NM Scientific Laboratory Division for biological testing. Preliminary information was collected from a limited number of individuals.


14

Staff from the NMDOH and NMED met with the water system manager to determine actual distribution line break dates and locations, water sampling dates, and to identify procedures which took place to disinfect the water after the line breaks. NMED field staff inspected the water system and pulled special samples from homes of people experiencing gastrointestinal symptoms. Water was checked not only for microbiological contamination but also for adequate chlorine residual. Results: The water system was tested for fecal indicator organisms on March 20, April 3, April 17, and April 22. Results of the water system testing by the water system operator and NMED indicated that there were no indicator bacteria in the system on any of the four sampling dates, and that the water contained a sufficient residual amount of chlorine to ensure adequate disinfection. Special samples taken at the home of some of the symptomatic residents showed no indicator bacteria. Spatially, the symptomatic individuals resided at or visited homes at the far end of the subdivision. Anecdotally, many of the symptomatic individuals had had contact with each other previous to becoming ill. The actual water line break locations were a substantial distance from the homes of the symptomatic individuals, and many homes with no reported symptomatic individuals lay between the line breaks and those residents. Additionally, NMED field staff reported an extremely poor hygiene situation in the home of the one of the affected families, including toddlers accessing the dirty diaper pail and poor kitchen hygiene. Bacteriological tests of the stool samples did not identify any bacterial disease-causing agents, however, virus testing showed that one of the samples was positive for viruses that cause gastrointestinal symptoms such as those described by the ill residents. Unfortunately, the other stool sample was of poor quantity and quality and could not be tested. Conclusions: Based on the preliminary information, it was determined that the gastrointestinal symptoms experienced by the residents were most likely the result of norovirus infection passed by direct contact from person-to-person. A full investigation was not initiated because there appeared to be no evidence of water-related disease transmission and no new cases were reported in the area. NMDOH obtained an information sheet from the US Centers for Disease Control and Prevention on preventing infectious disease, including information on handwashing, disinfection, food safety and other issues that the water system operator agreed to include in the next water bill. NMDOH worked with NMED to prepare a joint press release to alert the public that no connection was found between the water system and disease. Although this event was determined not to be an actual waterborne disease outbreak, the scenario allowed NMED and NMDOH to work together to test the system for investigating potential waterborne disease.


15

Other WDSP Outcomes The waterborne disease surveillance project had outcomes beyond simple disease and contaminant tracking. During 2002, a strong relationship was built between the NMED’s Drinking Water Bureau and NMDOH’s Office of Epidemiology. As a result of this strengthening relationship, several collaborative efforts were completed, including: Fact sheet development: A fact sheet on the health effects of Uranium was

developed in collaboration with NMED’s DWB and the NMED Ground Water Quality Bureau (see Appendix 2).

Presentations: New Mexico Environmental Health Conference, October, 2002: Waterborne Disease Surveillance in New Mexico (see Appendix 2).

Training initiatives: NMDOH provided a training session in disease outbreak investigation (foodborne/waterborne) for sanitarians at the Bernalillo County Environmental Health Department (September, 2002). A copy of presentation handouts is included in Appendix 2.

Collaboration on a potential waterborne disease cluster These initiatives are ongoing and are expected to continue. DISCUSSION Because of the sporadic nature and different risk factors for each of the seven selected diseases, it is difficult to draw broad conclusions regarding waterborne disease in New Mexico. There were no situations in which drinking water was definitively identified as the source of infection. Relative numbers of cases remained the similar to 2001 cases with the exception of shigellosis, which increased by about 99%. Several small, localized shigellosis clusters were identified and followed up by the Infectious Disease Epidemiology Unit; however, further examination revealed that different serotypes were involved, dispelling the notion that the increase represented a statewide outbreak. None of the clusters appeared to be water-related. 2002 was the second complete year of the waterborne disease surveillance project. The weekly surveillance system was operationalized mid-year, and led to identification of gaps in data collection. Some additional databases were developed to help track water quality and potential waterborne disease in the state. Currently, this system is a tracking system for enteric disease, of multiple and frequently unknown etiology. Utilization and fine-tuning of the databases and protocols will allow the implementation of a surveillance system that has the potential to differentiate waterborne disease from diseases of other etiology. Limitations. There are some major limitations to using reported enteric disease as a surveillance system for waterborne disease, including source determination, timeliness of reporting, recall bias, and reporting bias. Primarily, it is difficult to determine specific etiology for many diseases, especially those with relatively long incubation periods. To be confirmed, the potential source must be identified in time


16

to test it for the organism in question. Most of the selected enteric illnesses can be transmitted person-to-person, through food, or by animals in addition to waterborne transmission. Often, disease reports are not brought to public health practitioners’ attention until after many days or weeks of symptoms. It is difficult for most people to recall food and activity histories for events that happened many weeks in the past. Frequently, no follow-up risk factor information is collected. Reporting bias is also an issue. Certain infections may be more likely to be reported than others; also, specific populations may be more likely to be tested, for example those with HIV/AIDs, or other immune-suppressing disorders. An otherwise healthy person may be diagnosed based on clinical symptoms rather than a confirmatory test, and therefore, never reported. In addition, most people don’t seek medical care for diarrheal illness, preferring to self-medicate with over-the-counter medicines. Lastly, basing the surveillance system on reportable diseases may miss waterborne outbreaks of diseases that are not reportable. For example, some viruses, such as noroviruses, can be transmitted through water but are not reportable to the state. CONCLUSION 2002 was a year of operationalizing the waterborne disease surveillance project. Weekly analysis of data was initiated for two of the diseases, giardiasis and cryptosporidiosis in the first part of the year. The remaining 5 diseases were added by mid-year. Recommendations

1. Identify and monitor “susceptible systems”: With the help of NMED, criteria will be identified to determine whether a system is susceptible to contamination. These systems will be monitored carefully and may provide a location for secondary surveillance methods (see recommendation 2).

2. Investigate secondary surveillance systems: During 2003, two secondary surveillance methods will be investigated: Over-the-counter antidiarrheal sales monitoring and sentinel clinic surveillance. It is anticipated that one or both of these methods will be continued if they add valuable information on the burden of diarrheal disease in New Mexico.

3. Provide training for district NMED and NMDOH personnel: New Mexico is a large, rural state. Because it is not always possible for state personnel from Santa Fe to be on scene immediately during a disease outbreak, it is essential that staff from local district offices be trained in appropriate disease investigation protocol. NMDOH and NMED will continue to work together to provide statewide training opportunities.

4. Provide information for the general public, healthcare providers, and water system operators

5. Collaborate with DWB to perform an analysis of the DWB database to help prioritize development of health information (eg, radionuclides, volatile organic compounds [VOCs], synthetic organic compounds [SOCs], disinfection by products).


17

REFERENCES Chin, J (Ed.). (2000) Control of Communicable Diseases Manual (17th Edition) American Public Health Association. Food and Drug Administration (2001) Foodborne Pathogenic Microorganisms and Natural Toxins Handbook. Center for Food Safety and Applied Nutrition. [Online: http://www.cfsan.fda.gov/~mow]. Hunter, P. R. (1997) Waterborne Disease: Epidemiology and Ecology. Chichester, England: John Wiley & Sons, Ltd. New Mexico Administrative Code (NMAC) Title 20, Chapter 7, Part 1. Mead, P. S., Slutsker, L., Dietz, V., McCaig, L. F., Bresee, J., Shapiro, C., Griffin, P. M., and Tauxe, R. V. (2000). Food-related illness and death in the United States. Emerging Infectious Diseases, 5 (5). Appendices Appendix 1. Disease Specific Charts and Maps Appendix 2. Fact Sheets & Presentations


18

http://www.cfsan.fda.gov/~mow

APPENDIX 1, DISEASE SPECIFIC CHARTS AND MAPS


19

Definition of Terms: Rates: Rates were calculated as number of cases per 100,000 people using the 2000 US Census population, increased by the overall estimated 2001 New Mexico population increase (1.6%). Seasons: (Season of symptom onset) Winter: January, February, and December Spring: February, March, and April Summer: May, June, July, and August Fall: September, October, and November Residential water source: source of drinking water at home Recreational water exposure: exposure to lake, pond, swimming pool, river, or other source of water for recreational purposes. Potential sewage exposure: Combined variable includes any case that reported exposure to raw sewage, or have a home septic system or cesspool. Case contact: Case reported contact with someone with diarrhea within two weeks before or after onset of illness. Restaurant: Case reported eating at a restaurant within one week for a bacterial infection, two weeks for parasitic infections. Underlying illness: Case reported some sort of underlying illness. Those with underlying illnesses may have a higher likelihood of being tested than the general population. Travel: Case reported travel (any, outside New Mexico, or outside the US) within two weeks of symptom onset. Farm: Recent visit to a farm reported Sick animal: Contact with sick animals, including reptiles, poultry, cattle, or any other (e.g. sick pet). Food exposures: Nine different questions are asked regarding various food exposures, including raw meats (beef, chicken, eggs, shellfish, jerky), unpasteurized dairy products or cider, and unwashed fruits/vegetables. Different foods may be associated with each illness; for example, E. coli infection is often associated with undercooked beef, while campylobacter infection is more likely to be associated with undercooked chicken. Contaminated drinking water: Drinking water with documented microbial contamination at the time the illness occurred. This variable is unknown in all cases. Note: Reporting a positive risk factor does not necessarily indicate source of illness, for example, if a case reports swimming in a lake then reports illness, the illness may not necessarily be related to the lake water exposure. None of the variables is mutually exclusive; a single individual can be positive for more than one risk factor. A risk factor graph was not produced for amebiasis due to lack of data. A limited graph was produced for Hepatitis A, which generally has a long incubation period.


20

Reported Amebiasis in New Mexico, 2002 Total reported cases: 8

_W

Reported Amebiasis RatesNew Mexico 1990 - 2002

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Cas

es p

er 1

00,0

00 P

erso

ns

Special points of interest: Reported amebiasis has decreased

since the first half of the 1990s McKinley County reported the highest

rate in 2002 This disease appears to be uncommon

in New Mexico

LeaOtero

Catron

Eddy

Chaves

Socorro

Cibola

GrantSierra

Lincoln

Union

Luna

San Juan

McKinley

ColfaxRio Arr iba

Quay

Taos

Hidalgo

San MiguelSandoval

Dona Ana

Mora

TorranceGuadalupe

De Baca

Harding

Curry

Roosevelt

Santa Fe

Valencia

Bernalillo

Los AlamosMcKinley

Rate per 100,000012 - 34 - 7

Reported AmebiasisCounty Rate per 100,000 Persons

New Mexico, 2002N=8

_____________________________________________________aterborne Disease Surveillance Project Annual Report, 2002

Harding

LeaOtero

Catron

Eddy

Chaves

Socor ro

Cibola

GrantSierra

Lincoln

Union

Luna

San Juan

McKinley

ColfaxRio Arr iba

Quay

Taos

Hidalgo

San MiguelSandoval

Dona Ana

Mora

TorranceGuadalupe

De BacaCurry

Roosevelt

Santa Fe

Valenc ia

Bernalillo

Los Alamos

Reported Amebiasis (3-Year)County Rate per 100,000 Persons

New Mexico, 2002

____ 21

Reported Campylobacteriosis in New Mexico, 2002 Total reported cases: 347

_W

Reported Campylobacteriosis RatesNew Mexico 1990 - 2002

0

5

10

15

20

25

30

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Cas

es p

er 1

00,0

00 P

erso

ns

Special points of interest: Reported campylobacteriosis has remained

relatively stable since the early 1990s Summer was the most frequent season of

onset for this disease McKinley & Roosevelt Counties had the

highest rates during 2000-2002

LeaOtero

Catron

Eddy

Chaves

Cibola

Grant

Sierra

Lincoln

Union

Luna

San Juan ColfaxRio Arr iba

Quay

Taos

Hidalgo

San MiguelSandoval

Dona Ana

Mora

TorranceGuadalupe

Harding

Curry

Santa Fe

Valencia

Bernalillo

Los AlamosMcKinley

Socorro

De Baca

Roosevelt

Rate per 100,00001 - 2021 - 3637 - 68

Reported CampylobacteriosisCounty Rate per 100,000 Persons

New Mexico, 2002N=347

______________________________________________________aterborne Disease Surveillance Project Annual Report, 2002

OteroLea

Catron Socorro

Eddy

Chaves

SierraGrant

Cibola

Lincoln

Union

Luna

Rio ArribaSan Juan Colfax

Quay

Hidalgo

Taos

San MiguelSandoval

Dona Ana

Torrance

Mora

Guadalupe

Harding

De BacaCurry

Santa Fe

Valencia

Bernalillo

Los AlamosMcKinley

Roosevelt

Reported Campylobacteriosis (3-Year)County Rate per 100,000 Persons per Year

New Mexico, 2000-2002

___ 22

__________________________________________________________ Waterborne Disease Surveillance Project Annual Report, 2002 23

Reported Cases by Gender

Male53%

Female47%

Reported Rates by Agegroup

0.0

10.0

20.0

30.0

40.0

50.0

60.0

<11 t

o 4

5 to 1

4

15 to

24

25 to

34

35 to

44

45 to

54

55 to

64

65 to

74

75 to

84

over

85

Age Group

Cas

es p

er 1

00,0

00 p

eopl

eResidential Water Source

Public System

42%

Private Well10%

Unknown48%

No infections have been causally linked to this risk factor

Season of Onset

0

50

100

150

Season

Num

ber o

f Cas

es

Season 58 56 132 101

Winter Spring Summer Fall

Recreational Water Exposure

Yes4%

Unknown46%

No50%


Potential Sewage Exposure*

Yes19%

No 13%

Unknown68%


*includes those who report exposure to raw sewage, or have a home septic system or cesspool.

REPORTED CAMPYLOBACTERIOSIS, NEW MEXICO, 2002 General Case Characteristics & Possible Water Exposures Total reported cases: 347

REPORTED CAMPYLOBACTERIOSIS, NEW MEXICO, 2002 Weekly Surveillance and Risk Factor Information Total reported cases: 347

__W

Campylobacteriosis Risk Factors, New Mexico, 2002N=347

0%10%20%30%40%50%60%70%80%90%

100%

Restau

rant

Potenti

al Sew

age E

xpos

ure*

Underl

ying i

llnes

sFarm

Travel

Case C

ontac

t

Poultry

Dayca

re Ass

ociat

edJe

rky

Sick A

nimal

Recrea

tiona

l Wate

r

Raw C

hicke

n

Campin

g

Unpas

teuriz

ed M

ilk

Contam

inated

Drin

king W

ater

Yes No Unknown

________________________________________________________ aterborne Disease Surveillance Project Annual Report, 2002 24

Campylobacteriosis, New Mexico1990-2000 Average Weekly Rates & 1 Standard Deviation

2002 Weekly Rate

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53

MMWR Week

Cas

es p

er 1

00,0

00 p

erso

ns

AVG RT 1 STD 02_rt

January - March April - June July - September October - December

During week 41, 21 cases were reported in NM, 12 of which were in McKinley County, however, only 6 reported symptom onset during October

Reported Cryptosporidiosis in New Mexico, 2002 Total reported cases: 20

_W

Reported Cryptosporidiosis RatesNew Mexico, 1990 - 2002

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Cas

es p

er 1

00,0

00 P

erso

ns


Special points of interest: Cryptosporidiosis has shown a slight

decreasing trend, with the exception of a large increase in 1997

Guadalupe County had the highest rate in 2002

Cryptosporidiosis is a low incidence disease in NM; most counties reported no cases in 2002

LeaOtero

Catron

Eddy

Chaves

Socorro

Cibola

GrantSierra

Lincoln

Union

Luna

San Juan

McKinley

ColfaxRio Arr iba

Quay

Taos

Hidalgo

San MiguelSandoval

Dona Ana

Mora

TorranceGuadalupe

De Baca

Harding

Curry

Roosevelt

Santa Fe

Valencia

Bernalillo

Los Alamos

Guadalupe

Rate per 100,00001 - 23 - 1213 - 22

Reported CryptosporidiosisCounty Rate per 100,000 Persons


___ 25

LeaOtero

Catron

Eddy

Chaves

Socor ro

Cibola

GrantSierra

Lincoln

Union

Luna

San Juan

McKinley

ColfaxRio Arr iba

Quay

Taos

Hidalgo

San MiguelSandoval

Dona Ana

Mora

TorranceGuadalupe

Harding

Curry

Roosevelt

Santa Fe

Valenc ia

Bernalillo

Los Alamos

De Baca

Reported Cryptosporidiosis (3-Year)County Rate per 100,000 Persons per Year

New Mexico, 2000 - 2002



Yes20%

Unknown60%

No 20%



Season of Onset

0

2

4

6

8

10

12

Season

Num

ber o

f Cas

es

Season 3 5 11 1



Yes15%

Unknown25%

No60%



Male40%

Female60%


0.00.51.01.52.02.53.03.54.0

<11 t

o 4

5 to 1

4

15 to

24

25 to

34

35 to

44

45 to

54

55 to

64

65 to

74

75 to

84

over

85

Age Group

Cas

es p

er 1

00,0

00 p

eopl

eResidential Water Source

Public System

45%

Private Well10%

Unknown45%


REPORTED CRYPTOSPORIDIOSIS, NEW MEXICO, 2002 General Case Characteristics & Possible Water Exposures Total reported cases: 20

REPORTED CRYPTOSPORIDIOSIS, NEW MEXICO, 2002 Weekly Surveillance and Risk Factor Information Total reported cases: 20

Cryptosporidiosis Risk Factors, New Mexico, 2002N=20

0%10%20%30%40%50%60%70%80%90%

100%

Restau

rant

Travel

Potenti

al Sew

age E

xpos

ure*

Underl

ying i

llnes

s

Case c

ontac

t

Recrea

tiona

l Wate

rFarm

Dayca

re Ass

ociat

ed

Campin

g

Unpas

teuriz

ed C

ider

Sick A

nimal

Contam

inated

Drin

king W

ater

Yes No Unknown

Reported Cryptosporidiosis, New Mexico1990 -2000 Average Weekly Rates & 1 Standard Deviation

2002 Weekly Rates

0.000

0.050

0.100

0.150

0.200

0.250

0.300

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52

MMWR week

Rat

e pe

r 100

,000

AVG RT STDEV 02_rt

July - SeptemberApril - JuneJanuary - March October - December


Reported Enterohemorrhagic E. coli (EHEC) in New Mexico, 2002 Total reported cases: 17

_W

Reported E.coli (O157:H7 & Shiga toxin +) RatesNew Mexico, 1990 - 2002

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Cas

es p

er 1

00,0

00 P

erso

ns


LeaOtero

Catron

Eddy

Chaves

Socorro

Cibola

Grant

Sierra

Lincoln

Union

Luna

San Juan

McKinley

ColfaxRio Arr iba Taos

Hidalgo

San MiguelSandoval

Dona Ana

Mora

TorranceGuadalupe

De Baca

Harding

Curry

Roosevelt

Santa Fe

Valencia

Bernalillo

Los Alamos

Quay

Rate per 100,0000123 - 10

Reported Shiga Toxin-producing E. coliCounty Rate per 100,000 Persons


Special points of interest: This disease became reportable in

1993. Undercooked meat did not seem to

be an important risk factor in 2002. Bernalillo, Cibola, and Quay

Counties had the highest rates during 2000-2002.

___ 28

LeaOtero

Catron

Eddy

Chaves

Socor ro

Grant

Sierra

Lincoln

Union

Luna

San Juan

McKinley

ColfaxRio Arr iba Taos

Hidalgo

San MiguelSandoval

Dona Ana

Mora

TorranceGuadalupe

De Baca

Harding

Curry

Roosevelt

Santa Fe

Valenc ia

Los Alamos

CibolaBernalillo Quay

Reported E. coli (3-Year)County Rate per 100,000 Persons per Year

New Mexico, 2000 - 2002

_________________ Waterborne Disease Surveillance Project Annual Report, 2002 29


Yes24%

Unknown70%

No 6%



Residential Water Source

Unknown35%Private

Well18%

Public System

47%


Season of Onset

0

2

4

6

8

10

Season

Num

ber o

f Cas

es

Season 3 3 3 8



0.00.51.01.52.02.53.03.54.04.55.0

<11 t

o 4

5 to 1

4

15 to

24

25 to

34

35 to

44

45 to

54

55 to

64

65 to

74

75 to

84

over

85

Age Group

Cas

es p

er 1

00,0

00 p

eopl

e


Male71%

Female29%

REPORTED ENTEROHEMORRHAGIC E. COLI INFECTION, NM, 2002 General Case Characteristics & Possible Water Exposures Total reported cases: 17

_________________________________________


Yes0%

Unknown41%

No59%


REPORTED ENTEROHEMORRHAGIC E. COLI, NEW MEXICO, 2002 Weekly Surveillance and Risk Factor Information Total reported cases: 17

E. coli O157:H7, STX+ Risk Factors, New Mexico, 2002N=17

0%10%20%30%40%50%60%70%80%90%

100%

Restau

rant

Potenti

al Sew

age E

xpos

ure*

Case C

ontac

tFarm

Rare Bee

f

Underl

ying i

llnes

sJe

rky

Sick A

nimal

Recrea

tiona

l Wate

r

Unpas

teuriz

ed C

hees

e

Unpas

teuriz

ed C

ider

Unpas

teuriz

ed M

ilk

Contam

inated

Drin

king W

ater

Yes No Unknown


E. coli O157:H7 & STX+, New Mexico1993* - 2001 Average Weekly Rate & 1 Standard Deviation

2002 Weekly Rate

0.00

0.05

0.10

0.15

0.20

0.25

0.30

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53

Report Week

Cas

es p

er 1

00,0

00 p

erso

ns

AVG RT 1 STD 02_rt


* Reporting for this disease started in 1993

Elevated rate is a result of 2 cases of this low incidence disease

Reported Giardiasis in New Mexico, 2002 Total reported cases: 148

_W

Reported Giardiasis RatesNew Mexico 1990 - 2002

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Cas

es p

er 1

00,0

00 P

erso

ns

_____________________________________________________aterborne Disease Surveillance Project Annual Report, 2002

Special points of interest: Reported giardiasis has decreased

slightly since 1990 Four counties had the highest rates

in 2002: Santa Fe, Socorro, Dona Ana, & Hidalgo

Spring & summer were the highest reported onset seasons

OteroLea

Catron

Eddy

Chaves

Sierra

Grant

Cibola

Lincoln

Union

McKinley

Luna

Rio ArribaSan Juan Colfax

Quay

Taos

San MiguelSandoval

Torrance

Mora

Guadalupe

Harding

De BacaCurry

Roosevelt

Valencia

Bernalillo

Los Alamos

Socorro

Dona Ana

Hidalgo

Santa Fe

Rate per 100,00001 - 89 - 1112 - 18

Reported GiardiasisCounty Rate per 100,000 Persons


____ 31

LeaOtero

Catron

Eddy

Chaves

Socor ro

Cibola

GrantSierra

Lincoln

Luna

San Juan

McKinley

ColfaxRio Arr iba

Quay

Hidalgo

San MiguelSandoval

Mora

Guadalupe

De Baca

Harding

Curry

Roosevelt

Valenc ia

Bernalillo

Taos Union

Torrance

Santa Fe

Los Alamos

Dona Ana

Reported Giardiasis (3-Year)County Rate per 100,000 Persons per Year

New Mexico, 2000 - 2002

REPORTED GIARDIASIS, NEW MEXICO, 2002 General Case Characteristics & Possible Water Exposures Total reported cases: 148

___Waterborne Disease Surveillance Project Annual Report, 2002 32


Male52%

Female47%

Unknown1%

Season of Onset

0

10

20

30

40

50

Season

Num

ber o

f Cas

es

Season 36 42 43 27



Unknown42%

Public System

49%

Private Well9%



0.0

5.0

10.0

15.0

20.0

25.0

<11 t

o 4

5 to 1

4

15 to

24

25 to

34

35 to

44

45 to

54

55 to

64

65 to

74

75 to

84

over

85

Age Group

Cas

es p

er 1

00,0

00 p

eopl

e

______________


No 13%

Unknown71%

Yes16%



_________________________________________


Yes8%

Unknown41%

No51%


REPORTED GIARDIASIS, NEW MEXICO, 2002 Weekly Surveillance and Risk Factor Information Total reported cases: 148

Giardiasis Risk Factors, New Mexico, 2002N=148

0%10%20%30%40%50%60%70%80%90%

100%

Restau

rant

Travel

Potenti

al Sew

age E

xpos

ure*

Septic

Underl

ying i

llnes

s

Recrea

tiona

l Wate

r

Case C

ontac

t

Dayca

re Ass

ociat

ed

Campin

gFarm

Sick A

nimal

Contam

inated

Drin

king W

ater

Yes No Unknown

Giardiasis, New Mexico1990 -2000 Average Rate & 1 Standard Deviation

2002 Weekly Rate

0.000

0.100

0.200

0.300

0.400

0.500

0.600

0.700

0.800

0.900

1.000

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53

MMWR week

Rat

e pe

r 100

,000

AVG RT STDEV 02_rt


A line listing did not indicate any spatial clustering during week 17


Reported Hepatitis A infection in New Mexico, 2002 Total reported cases: 32

_W

Reported Hepatitis A Rates New Mexico, 1990 - 2002

0

10

20

30

40

50

60

70

80

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Cas

es p

er 1

00,0

00 P

erso

ns Targeted Hepatitis A vaccination begins

The NM rate was well above the national rate until 1996, when targeted immunization strategies decreased rates statewide

Most counties reported no cases in 2002

Approximately 30% reported international travel


LeaOtero

Catron

Eddy

Chaves

Socorro

Cibola

Grant

Sierra

Lincoln

UnionSan Juan

McKinley

ColfaxRio Arr iba

Quay

Taos

Hidalgo

San MiguelSandoval

Dona Ana

Mora

TorranceGuadalupe

De Baca

Harding

Curry

Roosevelt

Santa Fe

Valencia

Bernalillo

Los Alamos

Luna

Rate per 100,00001 - 23 - 56 - 13

Reported Hepatitis A InfectionCounty Rate per 100,000 Persons


___ 34

LeaOtero

Catron

Eddy

Chaves

Socor ro

Cibola

Sierra

Lincoln

UnionSan Juan

McKinley

ColfaxRio Arr iba

Quay

Taos

Hidalgo

San MiguelSandoval

Dona Ana

TorranceGuadalupe

De Baca

Harding

Curry

Roosevelt

Santa Fe

Bernalillo

Los Alamos

Grant

Luna

Valencia

Mora

Reported Hepatitis A Infection (3-Year)County Rate per 100,000 Persons per Year

New Mexico, 2000 - 2002

Waterborne Disease Surveillance Project Annual Report, 2002 35


Unknown35%Private

Well18%

Public System

47%


Season of Onset

0

2

4

6

8

10

Season

Num

ber o

f Cas

es

Season 3 3 3 8



Male71%

Female29%


0.00.51.01.52.02.53.03.54.04.55.0

<11 t

o 4

5 to 1

4

15 to

24

25 to

34

35 to

44

45 to

54

55 to

64

65 to

74

75 to

84

over

85

Age Group

Cas

es p

er 1

00,0

00 p

eopl

e

REPORTED HEPATITIS A INFECTION, NEW MEXICO, 2002 General Case Characteristics & Possible Water Exposures Total reported cases: 32

____________________________________________


Yes0%

Unknown41%

No59%


______________ No infections have been causally linked to this risk factor



Yes24%

Unknown70%

No 6%

REPORTED HEPATITIS A INFECTION, NEW MEXICO, 2002 Weekly Surveillance and Risk Factor Information Total reported cases: 32

Hepatitis A Risk Factors, New Mexico, 2002N=32

0%10%20%30%40%50%60%70%80%90%

100%

Intern

ation

al Trav

el

Case C

ontac

t

Dayca

re Con

tact

Dayca

re Ass

ociat

ed

Contam

inated

Drin

king W

ater

Yes No Unknown

__________________________________________________________

Reported Hepatitis A, New Mexico1998* - 2001 Average Weekly Rates & 1 Standard Devia

2002 Weekly Rates

0.000

0.050

0.100

0.150

0.200

0.250

0.300

0.350

0.400

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 4MMWR Report Week

Cas

es p

er 1

00,0

00 P

erso

ns

98-01AVG RT 1 STD 02_rt

January - March April - June July - September O

* Rate averages arfollowing a targetedprogram to enable

t

Waterborne Disease Surveillance Project Annual Report, 2002

Limited risk factor information was available for Hepatitis A

tion

3 45 47 49 51 53

ctober - December

e calculated for years immunization detection of elevated

36

Reported Shigellosis in New Mexico, 2002 Total reported cases: 243

_W

Reported Shigellosis RatesNew Mexico, 1990 - 2002

0

10

20

30

40

50

60

70

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Cas

es p

er 1

00,0

00 P

erso

ns


The reported Shigellosis trend is relatively stable with the exception of an extreme rate in 1995

McKinley County seems to be disproportionately affected by shigellosis

Most infections occurred in fall months

LeaOtero

Catron

Eddy

Chaves

Socorro

Cibola

GrantSierra

Lincoln

UnionSan Juan ColfaxRio Arr iba

Quay

Taos

Hidalgo

San MiguelSandoval

Dona Ana

Mora

TorranceGuadalupe

De Baca

Harding

Curry

Roosevelt

Santa Fe

Valencia

Bernalillo

Los AlamosMcKinley

Luna

Rate per 100,00001 - 1213 - 3132 - 88

Reported ShigellosisCounty Rate per 100,000 Persons


___ 37

LeaOtero

Catron

Eddy

Chaves

Socor ro

Cibola

Grant

Sierra

Lincoln

UnionSan Juan ColfaxRio Arr iba

Quay

Taos

Hidalgo

San MiguelSandoval

Dona Ana

Mora

TorranceGuadalupe

De Baca

Harding

Curry

Roosevelt

Santa Fe

Valenc ia

Bernalillo

Los AlamosMcKinley

Luna

Reported Shigellosis (3-Year)County Rate per 100,000 Persons per Year

New Mexico, 2000 - 2002



Unknown68%

No 23%

Yes9%




Yes3%

Unknown39%

No58%


Season of Onset

0

50

100

150

Season

Num

ber o

f Cas

es

Season 34 35 54 120



Unknown44%

Public System

49%

Private Well7%



0.05.0

10.015.020.025.030.035.040.045.0

<11 t

o 4

5 to 1

4

15 to

24

25 to

34

35 to

44

45 to

54

55 to

64

65 to

74

75 to

84

over

85

Age Group

Cas

es p

er 1

00,0

00 p

eopl

e


Male45%Female

54%

Unknown1%

REPORTED SHIGELLOSIS, NEW MEXICO, 2002 General Case Characteristics & Possible Water ExposuresTotal reported cases: 243

REPORTED SHIGELLOSIS, NEW MEXICO, 2002 Weekly Surveillance and Risk Factor Information Total reported cases: 243

Shigellosis Risk Factors, New Mexico, 2002N=243

0%10%20%30%40%50%60%70%80%90%

100%

Restau

rant

Case C

ontac

t

Travel

Potenti

al Sew

age E

xpos

ure*

Septic

Underl

ying i

llnes

s

Dayca

re Ass

ociat

ed

Recrea

tiona

l Wate

r

Unpas

teuriz

ed M

ilk

Unpas

teuriz

ed C

hees

e

Contam

inated

Drin

king W

ater

Yes No Unknown

Reported Shigellosis, New Mexico1991 - 2001 Average Weekly Rates & 1 Standard Deviation

2002 Weekly Rates

0.00

0.50

1.00

1.50

2.00

2.50

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53

MMWR Week

Cas

es p

er 1

00,0

00 p

erso

ns

AVG RT 1 STD 02_rt


During April 2002, there were 28 reported shigellosis cases in McKinley County, however onset spanned many weeks



APPENDIX 2, FACT SHEETS & PRESENTATIONS

Date post:	06-Dec-2021
Category:	Documents
Upload:	others
View:	5 times
Download:	0 times

New Mexico Waterborne Disease Surveillance Project Annual ...

Documents