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MMWR Surveill Summ. 2008 Sep 12;57(9):39-62.

Surveillance for waterborne disease and outbreaks associated with drinking water and water not intended for drinking--United States, 2005-2006.

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Division of Parasitic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, CDC, Atlanta, GA 30341, USA.

Erratum in

  • MMWR Surveill Summ. 2008 Oct 10;57(40):1105.



Since 1971, CDC, the U.S. Environmental Protection Agency (EPA), and the Council of State and Territorial Epidemiologists have maintained a collaborative Waterborne Disease and Outbreak Surveillance System (WBDOSS) for collecting and reporting data related to occurrences and causes of waterborne-disease outbreaks (WBDOs) and cases of waterborne disease. This surveillance system is the primary source of data concerning the scope and effects of waterborne disease in the United States.


Data presented summarize 28 WBDOs that occurred during January 2005--December 2006 and four previously unreported WBDOs that occurred during 1979--2002.


The surveillance system includes data on WBDOs associated with recreational water, drinking water, water not intended for drinking (WNID) (excluding recreational water), and water use of unknown intent. Public health departments in the states, territories, localities, and Freely Associated States (FAS) (i.e., the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau, formerly parts of the U.S.-administered Trust Territory of the Pacific Islands) are primarily responsible for detecting and investigating WBDOs and voluntarily reporting them to CDC by a standard form. Only cases and outbreaks associated with drinking water, WNID (excluding recreational water), and water of unknown intent (WUI) are summarized in this report. Cases and outbreaks associated with recreational water are reported in a separate Surveillance Summary.


Fourteen states reported 28 WBDOs that occurred during 2005--2006: a total of 20 were associated with drinking water, six were associated with WNID, and two were associated with WUI. The 20 drinking water-associated WBDOs caused illness among an estimated 612 persons and were linked to four deaths. Etiologic agents were identified in 18 (90.0%) of the drinking water-associated WBDOs. Among the 18 WBDOs with identified pathogens, 12 (66.7%) were associated with bacteria, three (16.7%) with viruses, two (11.1%) with parasites, and one (5.6%) mixed WBDO with both bacteria and viruses. In both WBDOs where the etiology was not determined, norovirus was the suspected etiology. Of the 20 drinking water WBDOs, 10 (50) were outbreaks of acute respiratory illness (ARI), nine (45%) were outbreaks of acute gastrointestinal illness (AGI), and one (5.0%) was an outbreak of hepatitis. All WBDOs of ARI were caused by Legionella, and this is the first reporting period in which the proportion of ARI WBDOs has surpassed that of AGI WBDOs since the reporting of Legionella WBDOs was initiated in 2001. A total of 23 deficiencies were cited in the 20 WBDOs associated with drinking water: 12 (52.2%) deficiencies fell under the classification NWU/POU (deficiencies occurred at points not under the jurisdiction of a water utility or at the point-of-use), 10 (43.5%) deficiencies fell under the classification SWTDs (contamination at or in the source water, treatment facility, or distribution system), and for one (4.3%) deficiency, classification was unknown. Among the 12 NWU/POU deficiencies, 10 (83.3%) involved Legionella spp. in the drinking water system. The most frequently cited SWTD deficiencies were associated with a treatment deficiency (n = four [40.0%]) and untreated ground water (n = four [40.0%]). Three of the four WBDOs with treatment deficiencies used ground water sources.


Approximately half (52.2%) of the drinking water deficiencies occurred outside the jurisdiction of a water utility. The majority of these WBDOs were associated with Legionella spp, which suggests that increased attention should be targeted towards reducing illness risks associated with Legionella spp. Nearly all of WBDOs associated with SWTD deficiencies occurred in systems using ground water. EPA's new Ground Water Rule might prevent similar outbreaks in the future in public water systems.


CDC and EPA use surveillance data to identify the types of water systems, deficiencies, and etiologic agents associated with WBDOs and to evaluate the adequacy of current technologies and practices for providing safe drinking water. Surveillance data also are used to establish research priorities, which can lead to improved water-quality regulation development. The majority of drinking water deficiencies are now associated with contamination at points outside the jurisdiction of public water systems (e.g., regrowth of Legionella spp. in hot water systems) and water contamination that might not be regulated by EPA (e.g., contamination of tap water at the POU). Improved education of consumers and plumbers might help address these risk factors.

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