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Epidemiology and Estimated Costs of a Large Waterborne Outbreak of Norovirus Infection in Sweden

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Epidemiology and Estimated Costs of a Large Waterborne Outbreak of Norovirus Infection in Sweden Epidemiol. Infect. (2014), 142, 592–600. © Cambridge University Press 2013 doi:10.1017/S0950268813001209 Epidemiology and estimated costs of a large waterborne outbreak of norovirus infection in Sweden C. LARSSON1*, Y. ANDERSSON2, G. ALLESTAM2,A.LINDQVIST1, 3 4 N. NENONEN AND O. BERGSTEDT 1 Department of Communicable Disease Control and Prevention, Region Västra Götaland, Sweden 2 Swedish Institute for Communicable Disease Control, Solna, Sweden 3 Department of Infectious Diseases/Virology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sweden 3 Water Environment Technology, Chalmers University of Technology, and Göteborg Vatten, Gothenburg, Sweden Received 5 January 2013; Final revision 12 April 2013; Accepted 24 April 2013; first published online 29 May 2013 SUMMARY A large outbreak of norovirus (NoV) gastroenteritis caused by contaminated municipal drinking water occurred in Lilla Edet, Sweden, 2008. Epidemiological investigations performed using a questionnaire survey showed an association between consumption of municipal drinking water and illness (odds ratio 4·73, 95% confidence interval 3·53–6·32), and a strong correlation between the risk of being sick and the number of glasses of municipal water consumed. Diverse NoV strains were detected in stool samples from patients, NoV genotype I strains predominating. Although NoVs were not detected in water samples, coliphages were identified as a marker of viral contamination. About 2400 (18·5%) of the 13000 inhabitants in Lilla Edet became ill. Costs associated with the outbreak were collected via a questionnaire survey given to organizations and municipalities involved in or affected by the outbreak. Total costs including sick leave, were estimated to be ∼8700000 Swedish kronor (∼€0·87 million). Key words: Cost, epidemiology, norovirus, outbreak, waterborne. INTRODUCTION waterborne outbreaks in Sweden [5, 6] and waterborne Norovirus (NoV) is a common cause of acute gastro- outbreaks with NoV have also been reported from – enteritis. The virus is highly contagious and is trans- many other countries [4, 7 9]. This increase in fl mitted from person to person or via contaminated reported NoV waterborne outbreaks may re ect the food or water [1]. Transmission of pathogens via improved molecular diagnostic methods now avail- municipal drinking water may affect a large popu- able for detection of the non-cultivable NoV in en- vironmental waters, and in patient samples. NoV are lation and thereby cause considerable economic and fi fi health impact [2–4]. During the last few years NoV genetically classi ed into ve genogroups, known as – has been identified in an increasing number of GI GV, where strains of NoV GI, GII and GIV can cause infections in humans [10]. Within a genogroup, NoV strains are further divided into a number of gen- otypes on the basis of capsid nucleotide sequence [11]. * Author for correspondence: Dr C. Larsson, Department of Although NoV GI strains tend to dominate in water- Communicable Disease Control and Prevention, Region Västra Götaland, Sweden. related outbreaks both NoV GI and GII and mixtures (Email: [email protected]) of NoV strains have been reported from waterborne Downloaded from https://www.cambridge.org/core. IP address: 170.106.35.229, on 28 Sep 2021 at 15:36:06, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268813001209 Waterborne norovirus outbreak in Sweden 593 infections [4, 5, 9, 12] whereas GII strains predomi- Of the 13000 inhabitants in Lilla Edet about 7500 nate in reports from institutional outbreaks [13, 14]. are supplied by drinking water from the Lilla Edet NoV are excreted in the faeces of infected humans water treatment plant (WTP). Other households in and therefore found in sewage and contaminated Lilla Edet are supplied by another WTP or by private surface water, which in turn may occasionally con- wells. It became obvious by the second day of the taminate drinking water systems resulting in water- outbreak that cases with gastrointestinal symptoms borne outbreaks [15, 16]. Discharges of treated and were concentrated in households supplied by Lilla untreated municipal wastewater and heavy rain are Edet WTP and the boil water recommendation was important risk factors for peak concentrations of amended to include only households supplied by this pathogens in surface water [17]. In contrast to the indi- WTP. cator bacteria, such as Escherichia coli, which are used The WTP in Lilla Edet uses raw water from the for measuring the quality of drinking water, the non- Göta Älv river with microbial barriers in the treatment cultivable human NoV are described as moderately process including pre-chlorination, coagulation/direct resistant to chlorination and may therefore be present filtration and post-chlorination. August 2008 was a in spite of the presence of chlorine [18, 19]. month with unusually high precipitation in the The impact on the whole community may be signifi- Göta Älv river valley and during the first week in cant during a waterborne outbreak. In particular the September heavy rains continued to fall on the already economic losses associated with the outbreak may be saturated ground. As a consequence of heavy rainfall substantial depending on the characteristics of the out- events at the end of this extremely wet period, eight break including the causative agent, the number of combined sewer overflows were activated in the muni- people affected and the duration of the outbreak [3]. cipality of Trollhättan, located 20 km upstream, and Early identification of waterborne outbreaks and six combined sewer overflows in Lilla Edet were ac- prompt establishment of control measures may play tivated upstream of the water intake to the Lilla Edet a major role in reducing the total number of sick indi- WTP. Moreover, on 2 September, untreated waste- viduals and the economic impact of the outbreak. water was released into one of the tributaries upstream A large waterborne outbreak of NoV occurred in of the intake due to an emergency discharge [21]. Lilla Edet in Sweden in 2008. The molecular charac- An outbreak investigation team was promptly teristics of the NoV strains from patients in this out- formed, initiated by the CMO, and included represen- break have been reported previously [20]. In this tatives from Lilla Edet municipality, National Food study we describe the outbreak from an epidemiologi- Agency, County Administrative Board, National cal perspective, also taking the costs associated with Water Emergency Team (VAKA), Swedish Institute the outbreak into consideration. for Communicable Disease Control (SMI), Depart- ment of Clinical Virology at Sahlgrenska University Hospital, Lilla Edet PHC, Department of Communi- METHODS cation, and Department of Communicable Disease Control and Prevention, Region Västra Götaland. Outbreak description Investigations were initiated to identify the causa- On 11 September 2008, the County Medical Officer tive agents, the extent of the outbreak and possible (CMO) was informed about an unusually high num- sources of infection. Efforts were also made to inform ber of individuals who had suddenly fallen ill with the inhabitants in the municipality about the ongoing gastrointestinal symptoms during the previous days outbreak, the issued boil water recommendation, in Lilla Edet, a small municipality in southwest and medical advice for people with gastrointestinal Sweden. Cases of gastroenteritis were reported from symptoms. Information was spread via the media, different places in the municipality, e.g. from the nur- the homepage of the municipality website, posters sery schools, schools, nursing homes and from the and local radio as ‘VMA’, i.e ‘important message to Primary Healthcare Centre (PHC). The CMO notified the public’. the Environmental Office in the municipality about In addition to the cases reported from the munici- the ongoing outbreak. As the initial information indi- pality of Lilla Edet, the CMO was notified that 7/17 cated that drinking water was a possible source of the athletes of a team that had visited the municipality outbreak a boil water recommendation was issued on during the afternoon on 7 September had fallen ill the same day. with gastrointestinal symptoms 2 days after their Downloaded from https://www.cambridge.org/core. IP address: 170.106.35.229, on 28 Sep 2021 at 15:36:06, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268813001209 594 C. Larsson and others visit. The athletes were reported to have drunk Water samples, i.e. raw water from the Göta Älv municipal water and not eaten during their short visit. river, drinking water from different parts of the distri- bution network, and water from reservoirs in Lilla Edet, were collected on 12 September and analysed Epidemiological investigation at the microbiological laboratory at SMI for the pres- To estimate the proportion of the 13000 inhabitants in ence of E. coli and coliform bacteria by Colilert 18 Lilla Edet that fell sick during the outbreak, question- (IDEXX, USA), intestinal enterococci by Enterolert naires were sent by mail on 19 September to 1199 (IDEXX), (oo)cysts of Giardia spp. and Crypto- randomly selected inhabitants between the ages of sporidium spp. according to ISO 15553:2006, Clostri- 19 and 75 years. A follow-up reminder letter about dium perfringens according to ISO/CD 6461-2:2002, the questionnaire was sent out about 2 weeks later. somatic coliphages according to ISO 10705-1:2000, The inhabitants aged 475 years represented 93% Campylobacter spp. by culture on CCDA agar of the population. The municipality of Lilla Edet (in-house method), Salmonella spp. according to ISO includes seven minor geographical areas with separate 6340:1995, Verotoxin-producing E. coli (VTEC) by postal codes, which were all included in the sampling. PCR screening for vt genes and NoV by semi-nested The questionnaire included questions about all mem- PCR [22]. Additional water samples were collected bers, i.e. both children and adults, in the household.
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