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In June 2021, Kansas state and county public health officials identified and investigated three cases of shigellosis (a bacterial diarrheal illness caused by Shigella spp.) associated with visiting a wildlife park. The park has animal exhibits and a splash pad. Two affected persons visited animal exhibits, and all three entered the splash pad. Nonhuman primates are the only known animal reservoir of Shigella. The splash pad, which sprays water on users and is designed so that water does not collect in the user area, was closed on June 19. The state and county public health codes do not include regulations for splash pads. Thus, these venues are not typically inspected, and environmental health expertise is limited. A case-control study identified two distinct outbreaks associated with the park (a shigellosis outbreak involving 21 cases and a subsequent norovirus infection outbreak involving six cases). Shigella and norovirus can be transmitted by contaminated water; in both outbreaks, illness was associated with getting splash pad water in the mouth (multiply imputed adjusted odds ratio [aOR

Outbreaks associated with treated recreational water can be caused by pathogens or chemicals in aquatic venues such as pools, hot tubs, water playgrounds, or other artificially constructed structures that are intended for recreational or therapeutic purposes. For the pseriod 2015-2019, public health officials from 36 states and the District of Columbia (DC) voluntarily reported 208 outbreaks associated with treated recreational water. Almost all (199; 96%) of the outbreaks were associated with public (nonbackyard) pools, hot tubs, or water playgrounds. These outbreaks resulted in at least 3,646 cases of illness, 286 hospitalizations, and 13 deaths. Among the 155 (75%) outbreaks with a confirmed infectious etiology, 76 (49%) were caused by Cryptosporidium (which causes cryptosporidiosis, a gastrointestinal illness) and 65 (42%) by Legionella (which causes Legionnaires' disease, a severe pneumonia, and Pontiac fever, a milder illness with flu-like symptoms). Cryptosporidium accounted for 2,492 (84%) of 2,953 cases resulting from the 155 outbreaks with a confirmed etiology. All 13 deaths occurred in persons affected by a Legionnaires' disease outbreak. Among the 208 outbreaks, 71 (34%) were associated with a hotel (i.e., hotel, motel, lodge, or inn) or a resort, and 107 (51%) started during June-August. Implementing recommendations in CDC's Model Aquatic Health Code (MAHC) (1) can help prevent outbreaks associated with treated recreational water in public aquatic venues.

The parasite Cryptosporidium hominis is a leading cause of the diarrheal disease cryptosporidiosis, whose incidence in the United States has increased since 2005. Here, we show that the newly emerged and hyper-transmissible subtype IfA12G1R5 is now dominant in the United States. In a comparative analysis of 127 newly sequenced and 95 published C. hominis genomes, IfA12G1R5 isolates from the United States place into three of the 14 clusters (Pop6, Pop13, and Pop14), indicating that this subtype has multiple ancestral origins. Pop6 (IfA12G1R5a) has an East Africa origin and has recombined with autochthonous subtypes after its arrival. Pop13 (IfA12G1R5b) is imported from Europe, where it has recombined with the prevalent local subtype, whereas Pop14 (IfA12G1R5c) is a progeny of secondary recombination between Pop6 and Pop13. Selective sweeps in invasion-associated genes have accompanied the emergence of the dominant Pop14. These observations offer insights into the emergence and evolution of hyper-transmissible pathogens.

Outbreaks associated with fresh or marine (i.e., untreated) recreational water can be caused by pathogens or chemicals, including toxins. Voluntary reporting of these outbreaks to CDC's National Outbreak Reporting System (NORS) began in 2009. NORS data for 2009-2017 are finalized, and data for 2018-2019 are provisional. During 2009-2019 (as of May 13, 2020), public health officials from 31 states voluntarily reported 119 untreated recreational water-associated outbreaks, resulting at least 5,240 cases; 103 of the outbreaks (87%) started during June-August. Among the 119 outbreaks, 88 (74%) had confirmed etiologies. The leading etiologies were enteric pathogens: norovirus (19 [22%] outbreaks; 1,858 cases); Shiga toxin-producing Escherichia coli (STEC) (19 [22%]; 240), Cryptosporidium (17 [19%]; 237), and Shigella (14 [16%]; 713). This report highlights three examples of outbreaks that occurred during 2018-2019, were caused by leading etiologies (Shigella, norovirus, or STEC), and demonstrate the wide geographic distribution of such outbreaks across the United States. Detection and investigation of untreated recreational water-associated outbreaks are challenging, and the sources of these outbreaks often are not identified. Tools for controlling and preventing transmission of enteric pathogens through untreated recreational water include epidemiologic investigations, regular monitoring of water quality (i.e., testing for fecal indicator bacteria), microbial source tracking, and health policy and communications (e.g., observing beach closure signs and not swimming while ill with diarrhea).

Cryptosporidium is a parasite that causes cryptosporidiosis, a profuse, watery diarrhea that can last up to 3 weeks in immunocompetent patients and can lead to life-threatening malnutrition and wasting in immunocompromised patients.* Fecal-oral transmission can occur by ingestion of contaminated recreational water, drinking water, or food, or through contact with infected persons or animals. For the period 2009-2017, public health officials from 40 states and Puerto Rico voluntarily reported 444 cryptosporidiosis outbreaks resulting in 7,465 cases. Exposure to treated recreational water (e.g., in pools and water playgrounds) was associated with 156 (35.1%) outbreaks resulting in 4,232 (56.7%) cases. Other predominant outbreak exposures included contact with cattle (65 outbreaks; 14.6%) and contact with infected persons in child care settings (57; 12.8%). The annual number of reported cryptosporidiosis outbreaks overall increased an average of approximately 13% per year over time. Reversing this trend will require dissemination of prevention messages to discourage swimming or attending child care while ill with diarrhea and encourage hand washing after contact with animals. Prevention and control measures can be optimized by improving understanding of Cryptosporidium transmission through regular analysis of systematically collected epidemiologic and molecular characterization data.

Harmful algal bloom events can result from the rapid growth, or bloom, of photosynthesizing organisms in natural bodies of fresh, brackish, and salt water. These events can be exacerbated by nutrient pollution (e.g., phosphorus) and warming waters and other climate change effects (1); have a negative impact on the health of humans, animals, and the environment; and damage local economies (2,3). U.S. harmful algal bloom events of public health concern are centered on a subset of phytoplankton: diatoms, dinoflagellates, and cyanobacteria (also called blue-green algae). CDC launched the One Health Harmful Algal Bloom System (OHHABS) in 2016 to inform efforts to prevent human and animal illnesses associated with harmful algal bloom events. A total of 18 states reported 421 harmful algal bloom events, 389 cases of human illness, and 413 cases of animal illness that occurred during 2016-2018. The majority of harmful algal bloom events occurred during May-October (413; 98%) and in freshwater bodies (377; 90%). Human and animal illnesses primarily occurred during June-September (378; 98%) and May-September (410; 100%). Gastrointestinal or generalized illness signs or symptoms were the most frequently reported (>40% of human cases and >50% of animal cases); however, multiple other signs and symptoms were reported. Surveillance data from harmful algal bloom events, exposures, and health effects provide a systematic description of these occurrences and can be used to inform control and prevention of harmful algal bloom-associated illnesses.

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.

Cryptosporidiosis is a nationally notifiable gastrointestinal illness caused by parasitic protozoa of the genus Cryptosporidium, which can cause profuse, watery diarrhea that can last up to 2-3 weeks in immunocompetent patients and can lead to life-threatening wasting and malabsorption in immunocompromised patients. Fecal-oral transmission of Cryptosporidium oocysts, the parasite's infectious life stage, occurs via ingestion of contaminated recreational water, drinking water, or food, or following contact with infected persons or animals, particularly preweaned bovine calves (1). The typical incubation period is 2-10 days. Since 2004, the annual incidence of nationally notified cryptosporidiosis has risen approximately threefold in the United States (1). Cryptosporidium also has emerged as the leading etiology of nationally notified recreational water-associated outbreaks, particularly those associated with aquatic facilities (i.e., physical places that contain one or more aquatic venues [e.g., pools] and support infrastructure) (2). As of February 24, 2017, a total of 13 (54%) of 24 states reporting provisional data detected at least 32 aquatic facility-associated cryptosporidiosis outbreaks in 2016. In comparison, 20 such outbreaks were voluntarily reported to CDC via the National Outbreak Reporting System for 2011, 16 for 2012, 13 for 2013, and 16 for 2014. This report highlights cryptosporidiosis outbreaks associated with aquatic facilities in three states (Alabama, Arizona, and Ohio) in 2016. This report also illustrates the use of CryptoNet, the first U.S. molecularly based surveillance system for a parasitic disease, to further elucidate Cryptosporidium chains of transmission and cryptosporidiosis epidemiology. CryptoNet data can be used to optimize evidence-based prevention strategies. Not swimming when ill with diarrhea is key to preventing and controlling aquatic facility-associated cryptosporidiosis outbreaks (https://www.cdc.gov/healthywater/swimming/swimmers/steps-healthy-swimming.html).

Pool chemicals are added to water in treated recreational water venues (e.g., pools, hot tubs/spas, and water playgrounds) primarily to protect public health. Pool chemicals inactivate pathogens (e.g., chlorine or bromine), optimize pH (e.g., muriatic acid), and increase water clarity, which helps prevent drowning by enabling detection of distressed swimmers underwater. However, pool chemicals can cause injuries if mishandled. To estimate the annual number of U.S. emergency department (ED) visits for pool chemical injuries, CDC analyzed 2008-2017 data from the National Electronic Injury Surveillance System (NEISS), operated by the U.S. Consumer Product Safety Commission (CPSC). During 2015-2017, pool chemical injuries led to an estimated 13,508 (95% confidence interval [CI] = 9,087-17,929) U.S. ED visits; 36.4% (estimated 4,917 [95% CI = 3,022-6,811]) of patients were aged

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

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.

SUMMARYGiardia intestinalisis the leading parasitic aetiology of human enteric infections in the United States, with an estimated 1·2 million cases occurring annually. To better understand transmission, we analysed data on all giardiasis outbreaks reported to the Centers for Disease Control and Prevention for 1971–2011. The 242 outbreaks, affecting ~41 000 persons, resulted from waterborne (74·8%), foodborne (15·7%), person-to-person (2·5%), and animal contact (1·2%) transmission. Most (74·6%) waterborne outbreaks were associated with drinking water, followed by recreational water (18·2%). Problems with water treatment, untreated groundwater, and distribution systems were identified most often during drinking water-associated outbreak investigations; problems with water treatment declined after the 1980s. Most recreational water-associated outbreaks were linked to treated swimming venues, with pools and wading pools implicated most often. Produce was implicated most often in foodborne outbreaks. Additionally, foods were most commonly prepared in a restaurant and contaminated by a food handler. Lessons learned from examining patterns in outbreaks over time can help prevent future disease. Groundwater and distribution system vulnerabilities, inadequate pool disinfection, fruit and vegetable contamination, and poor food handler hygiene are promising targets for giardiasis prevention measures.

During the 2012 summer swim season, aquatic venue data and filter backwash samples were collected from 127 metro-Atlanta pools. Last-recorded water chemistry measures indicated 98% (157/161) of samples were from pools with ≥1 mg/L residual chlorine without stabilized chlorine or ≥2 mg/L with stabilized chlorine and 89% (144/161) had pH readings 7.2–7.8. These water quality parameters are consistent with the 2016 Model Aquatic Health Code (2nd edition) recommendations. We used previously validated real-time polymerase chain reaction assays for detection of seven enteric microbes, including Escherichia coli, and Pseudomonas aeruginosa. E. coli was detected in 58% (93/161) of samples, signifying that swimmers likely introduced fecal material into pool water. P. aeruginosa was detected in 59% (95/161) of samples, indicating contamination from swimmers or biofilm growth on surfaces. Cryptosporidium spp. and Giardia duodenalis were each detected in approximately 1% of samples. These findings indicate the need for aquatics staff, state and local environmental health practitioners, and swimmers to each take steps to minimize the risk of transmission of infectious pathogens.

We investigated a gastrointestinal illness cluster among persons who attended a baseball tournament (200 teams) during July 2015. We interviewed representatives of 19 teams; illness was reported among only the 9 (47%) teams that stayed at Hotel A (p.01). We identified 55 primary cases. A case-control study demonstrated that pool exposure at Hotel A was significantly associated with illness (odds ratio: 7.3; 95% confidence interval: 3.6, 15.2). Eight out of nine (89%) stool specimens tested were positive for Cryptosporidium, with C. hominis IfA12G1 subtype identified in two specimens. The environmental health assessment detected a low free available chlorine level, and pool water tested positive for E. coli and total coliforms. A possible diarrheal contamination event, substantial hotel pool use, and use of cyanuric acid might have contributed to this outbreak and magnitude. Aquatic facilities practicing proper operation and maintenance (e.g., following the Centers for Disease Control and Prevention’s Model Aquatic Health Code) can protect the public’s health.

Background Naegleria fowleri is a thermophilic ameba that is found in freshwater and causes primary amebic meningoencephalitis (PAM; 0–8 infections per year in the United States) when it enters the nose and migrates to the brain. Patient exposure to water containing the ameba typically occurs in warm freshwater lakes and ponds during recreational water activities. In September 2018, a 29-year-old man died of PAM after visiting a Texas inland surf park. Methods To determine water exposures, we reviewed medical records and conducted interviews with family and individuals who had traveled with the patient. To further investigate the inland surf park as a possible exposure source, we visited the facility and collected water, biofilm, and sediment samples from the surf park and other venues (water slides, lazy river, and cable park) within the facility. We assessed water sources and treatment practices, performed water quality tests, and tested for the presence of N. fowleri by culture and real-time PCR. Results Interviews revealed that the case-patient’s most probable water exposure in the 10 days before becoming ill occurred while surfing in an inland freshwater surf park where he fell off the surfboard into the water multiple times. The on-site investigation of the facility revealed a practice of manual chlorine treatment with monitoring, but no water filtering or record keeping to document water quality. Surf park water temperature was warm (25°C) and chlorine residual was negligible. N. fowleri was detected in 1 water and 1 sediment sample collected at the cable park venue, and viable thermophilic amebae were detected in all samples collected from the surf park, water slide, and cable park venues, as well from the sediment in the open-air groundwater reservoir feeding the venues. Conclusion This investigation documents a novel exposure in an inland surf park as the likely exposure causing PAM. Conditions in the surf park were conducive to amebic growth. Novel types of recreational water venues that do not meet traditional definitions of swimming pools, such as this surf park, might not meet the water quality standards for pools or similar treated venues. Clinicians and public health officials should remain vigilant for nontraditional exposures to water. Disclosures All authors: No reported disclosures.

Acute otitis externa (AOE) is a common but preventable ear condition. Clinical guidelines issued in 2006 recommended topical treatments for uncomplicated AOE, but systemic antimicrobials appear to be commonly prescribed. The objective of this analysis was to describe pre- and postguideline prescribing patterns by clinician specialty and antimicrobial type and assess trends over time.Retrospective longitudinal analysis of a large insurance database.Outpatient departments in the United States.Initial outpatient visits in 2004 to 2010 for AOE (excluding visits with complicating conditions) were extracted from an insurance database. Prescription drug claims were linked and categorized by clinician specialty and antimicrobial type.The analysis included 907,261 initial outpatient visits. Use of systemic antimicrobials declined by 4.9% (95% confidence interval [CI], 4.1%, 5.7%) from 36.5% of initial visits in 2004 to 32.1% in 2010. Use of systemic antimicrobials varied by specialty. Systemic antimicrobials were prescribed in 47.1% of 2010 emergency department (ED) visits (-6.9% from 2004, 95% CI -12.3, -1.5), 25.9% of otolaryngologist visits (-1.6%, 95% CI -5.6, 2.4), and 20.4% of pediatrician visits (-6.6%, 95% CI -8.8, -4.4). Penicillins were prescribed most frequently (42.3% of systemic prescriptions in 2010), followed by cephalosporins (19.8%), erythromycin/macrolides (17.4%), and quinolones (11.1%). Opioids were prescribed in 26.4% of ED visits and 9% of outpatient visits.Use of systemic antimicrobials declined over time, but one-third of 2010 visits resulted in systemic antimicrobials, despite exclusion of visits with complicating factors. Use of systemic antimicrobials varied by specialty. Further educational efforts and outreach to other specialties might be warranted.

Subtyping was conducted in late 2007 on 57 Cryptosporidium specimens from sporadic cases in Colorado, Idaho, New Mexico, and Iowa. One previously rare Cryptosporidium hominis subtype was indentified in 40 cases (70%) from all four states, and the Cryptosporidium horse genotype was identified in a pet shop employee with severe clinical symptoms.

Cyanuric acid (CYA) is a chlorine stabilizer used in swimming pools to limit UV degradation of chlorine, thus reducing chlorine use and cost. However, CYA has been shown to decrease the efficacy of chlorine disinfection. In the event of a diarrheal incident, CDC recommends implementing 3-log10 inactivation conditions for Cryptosporidium (CT value = 15 300 mg·min/L) to remediate pools. Currently, CYA's impact on Cryptosporidium inactivation is not fully determined. We investigated the impact of multiple concentrations of CYA on C. parvum inactivation (at 20 and 40 mg/L free chlorine; average pH 7.6; 25 °C). At 20 mg/L free chlorine, average estimated 3-log10 CT values were 17 800 and 31 500 mg·min/L with 8 and 16 mg/L CYA, respectively, and the average estimated 1-log10 CT value was 76 500 mg·min/L with 48 mg/L CYA. At 40 mg/L free chlorine, 3-log10 CT values were lower than those at 20 mg/L, but still higher than those of free chlorine-only controls. In the presence of ∼100 mg/L CYA, average 0.8- and 1.4-log10 reductions were achieved by 72 h at 20 and 40 mg/L free chlorine, respectively. This study demonstrates CYA significantly delays chlorine inactivation of Cryptosporidium oocysts, emphasizing the need for additional pool remediation options following fecal incidents.

In July 2014, Multnomah County public health officials investigated a norovirus outbreak among persons visiting Blue Lake Regional Park in Oregon. During the weekend of the reported illnesses (Friday, July 11-Sunday, July 13) approximately 15,400 persons visited the park. The investigation identified 65 probable and five laboratory-confirmed cases of norovirus infection (70 total cases). No hospitalizations or deaths were reported. Analyses from a retrospective cohort study revealed that swimming at Blue Lake during July 12-13 was significantly associated with illness during July 13-14 (adjusted relative risk = 2.3; 95% confidence interval [CI] = 1.1-64.9). Persons who swam were more than twice as likely to become ill compared with those who did not swim in the lake. To control the outbreak, Blue Lake was closed for 10 days to prevent further illness. This investigation underscores the need for guidance for determining when to reopen untreated recreational water venues (e.g., lakes) associated with outbreaks, and communication tools to inform the public about the risks associated with swimming in untreated recreational water venues and measures that can prevent illness.

Cryptosporidiosis is a nationally notifiable gastrointestinal illness caused by extremely chlorine-tolerant protozoa of the genus Cryptosporidium.2011-2012.Fifty state and two metropolitan public health agencies voluntarily report cases of cryptosporidiosis through CDC's National Notifiable Diseases Surveillance System.For 2011, a total of 9,313 cryptosporidiosis cases (confirmed and nonconfirmed) were reported; for 2012, a total of 8,008 cases were reported; 5.8% and 5.3%, respectively, were associated with a detected outbreak. The rates of reported nonconfirmed cases were 1.0 and 0.9 per 100,000 population in 2011 and 2012, respectively, compared with an average of 0.0 during 1995-2004, and 0.3 during 2005-2010. The highest overall reporting rates were observed in the Midwest; 10 states reported3.5 cases per 100,000 population in 2011 and in 2012. During 2011-2012, reported cases were highest among children aged 1-4 years (6.6 per 100,000 population), followed for the first time by elderly adults aged ≥80 years (3.4), and 75-79 years (3.3). Overall, cryptosporidiosis rates were higher among females than males during both years. For specific age groups, rates were higher among males than females aged15 years and higher among females than males aged ≥15 years. Cryptosporidiosis symptom onset increased 4.4 fold during late summer.Cryptosporidiosis incidence rates remain elevated nationally, and rates of nonconfirmed cases have increased. Rates remain highest in young children, although rates among elderly adults are increasing. Transmission of Cryptosporidium occurs throughout the United States, with increased reporting occurring in Midwestern states. Seasonal onset peaks coincide with the summer recreational water season and might reflect increased use of communal swimming venues.Future research is needed to address the evolving epidemiology of cryptosporidiosis cases, with a specific focus on the increase in nonconfirmed cases and increasing incidence rates among elderly adults. National systematic genotyping and subtyping of Cryptosporidium isolates could also help elucidate Cryptosporidium transmission and thus cryptosporidiosis epidemiology in the United States.

SUMMARYThe incidence of recreational water-associated outbreaks in the United States has significantly increased, driven, at least in part, by outbreaks both caused byCryptosporidiumand associated with treated recreational water venues. Because of the parasite's extreme chlorine tolerance, transmission can occur even in well-maintained treated recreational water venues (e.g. pools) and a focal cryptosporidiosis outbreak can evolve into a community-wide outbreak associated with multiple recreational water venues and settings (e.g. childcare facilities). In August 2004 in Auglaize County, Ohio, multiple cryptosporidiosis cases were identified and anecdotally linked to pool A. Within 5 days of the first case being reported, pool A was hyperchlorinated to achieve 99·9%Cryptosporidiuminactivition. A case-control study was launched to epidemiologically ascertain the outbreak source 11 days later. A total of 150 confirmed and probable cases were identified; the temporal distribution of illness onset was peaked, indicating a point-source exposure. Cryptosporidiosis was significantly associated with swimming in pool A (matched odds ratio 121·7, 95% confidence interval 27·4–∞) but not with another venue or setting. The findings of this investigation suggest that proactive implementation of control measures, when increasedCryptosporidiumtransmission is detected but before an outbreak source is epidemiologically ascertained, might prevent a focal cryptosporidiosis outbreak from evolving into a community-wide outbreak.

In 1977, an outbreak of toxoplasmosis occurred among 37 persons associated with exposure to an indoor horse arena. Cat feces containing the organism were most likely stirred up when horses ran on the dirt floor, and were inhaled or ingested by riders and observers. After 25 or more years, we attempted to locate persons from the outbreak and offer them an eye examination. Of the 37 persons in the outbreak, 18 (49%) were located; four had died, and the remaining 14 agreed to an examination. Among the 14 persons examined, three (21%) were found to have lesions typical of toxoplasmic retinochoroiditis. If these three persons were the only ones with ocular disease among the 37 persons in the outbreak, the disease rate would still be high (8%). As a result of exposure to Toxoplasma gondii during this outbreak, a relatively high percentage of persons developed ocular disease.

Introduction: Harmful algal blooms (HABs) are increasingly reported among fresh water bodies used for recreation. These blooms, primarily composed of cyanobacteria, are more likely to occur during ...

Pool chemicals are added to treated recreational water venues (e.g., pools, hot tubs/spas, and interactive fountains) primarily to protect public health by inactivating pathogens and maximizing the effectiveness of disinfection by controlling pH. However, pool chemicals also can cause injuries when handled or stored improperly. To estimate the number of emergency department (ED) visits for injuries associated with pool chemicals in the United States per year during 2003-2012, CDC analyzed data from the U.S. Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS). This report summarizes the results of that analysis. In 2012 alone, an estimated 4,876 persons (95% confidence interval [CI] = 2,821-6,930) visited an ED for injuries associated with pool chemicals. Almost half of the patients were aged18 years. This report also describes a pool chemical-associated health event that occurred in Minnesota in 2013, which sent seven children and one adult to an ED. An investigation by the Minnesota Department of Health (MDH) determined the cause to be poor monitoring of or response to pool chemistry. Pool chemical-associated health events are preventable. CDC's Model Aquatic Health Code (MAHC) (1) is a resource that state and local agencies can use to optimize prevention of injuries and illnesses associated with public treated recreational water venues, including pool chemical-associated health events.

The ability of chlorine dioxide (ClO2) to achieve 2-log inactivation of Cryptosporidium in drinking water has been documented. No studies have specifically addressed the effects of ClO2 on C. parvum oocyst infectivity in chlorinated recreational water venues (e.g., pools). The aim of this research was to determine the efficacy of ClO2 as an alternative to existing hyperchlorination protocols that are used to achieve a 3-log inactivation of Cryptosporidium in such venues. To obtain a 3-log inactivation of C. parvum Iowa oocysts, contact times of 105 and 128 min for a solution containing 5 mg/L ClO2 with and without the addition of 2.6 mg/L free chlorine, respectively, were required. Contact times of 294 and 857 min for a solution containing 1.4 mg/L ClO2 with and without the addition of 3.6 mg/L free chlorine, respectively, were required. The hyperchlorination control (21 mg/L free chlorine only) required 455 min for a 3-log inactivation. Use of a solution containing 5 mg/L ClO2 and solutions containing 5 or 1.4 mg/L ClO2 with the addition of free chlorine appears to be a promising alternative to hyperchlorination for inactivating Cryptosporidium in chlorinated recreational water venues, but further studies are required to evaluate safety constraints on use.

Recreational water-associated disease outbreaks result from exposure to infectious pathogens or chemical agents in treated recreational water venues (e.g., pools and hot tubs or spas) or untreated recreational water venues (e.g., lakes and oceans). For 2009-2010, the most recent years for which finalized data are available, public health officials from 28 states and Puerto Rico electronically reported 81 recreational water-associated disease outbreaks to CDC's Waterborne Disease and Outbreak Surveillance System (WBDOSS) via the National Outbreak Reporting System (NORS). This report summarizes the characteristics of those outbreaks. Among the 57 outbreaks associated with treated recreational water, 24 (42%) were caused by Cryptosporidium. Among the 24 outbreaks associated with untreated recreational water, 11 (46%) were confirmed or suspected to have been caused by cyanobacterial toxins. In total, the 81 outbreaks resulted in at least 1,326 cases of illness and 62 hospitalizations; no deaths were reported. Laboratory and environmental data, in addition to epidemiologic data, can be used to direct and optimize the prevention and control of recreational water-associated disease outbreaks.

In July 2008, clusters of laboratory-confirmed cryptosporidiosis cases and reports of gastrointestinal illness in persons who visited a lake were reported to Tarrant County Public Health. In response, epidemiologic, laboratory, and environmental health investigations were initiated. A matched case-control study determined that swallowing the lake water was associated with illness (adjusted odds ratio = 16.3; 95% confidence interval: 2.5-infinity). The environmental health investigation narrowed down the potential sources of contamination. Laboratory testing detected Cryptosporidium hominis in case-patient stool specimens and Cryptosporidium species in lake water. It was only through the joint effort that epidemiologic, laboratory, and environmental health investigators could determine that1 human diarrheal fecal incidents in the lake likely led to contamination of the water. This same collaborative effort will be needed to develop and maintain an effective national Model Aquatic Health Code.

Cryptosporidiosis is a nationally notifiable gastrointestinal illness caused by extremely chlorine-tolerant protozoa of the genus Cryptosporidium.2009-2010.Fifty state and two metropolitan public health agencies voluntarily report cases of cryptosporidiosis through CDC's National Notifiable Diseases Surveillance System.For 2009, 7,656 confirmed and probable cases of cryptosporidiosis (2.5 per 100,000 population) were reported; for 2010, 8,951 confirmed and probable cases (2.9 per 100,000 population) were reported. All jurisdictions reported cryptosporidiosis cases for 2009-2010, and the number of jurisdictions reporting3.5 cases per 100,000 population was 18 for 2009 and 20 for 2010. Cases were most frequently reported in children aged 1-9 years, followed by adults aged 25-29 years. This is the first reporting period in which more cases of cryptosporidiosis were reported in females than in males. Peak onset of illness occurred during early summer through early fall; the sympton onset of cases in children aged 5-9 years peaked earlier than that of cases reported in adults aged 25-34 years.Transmission of Cryptosporidium occurs throughout the United States. Rate data from reporting jurisdictions should be compared with caution because individual jurisdictions have varying capacities to detect, investigate, and report cases. The symptom onset and age-specific peaks coincide with the summer recreational water season and might reflect increased use of communal swimming venues (e.g., swimming pools and interactive fountains) by young children who then transmit the parasite to other users and their caregivers.Local, state, and federal public health agencies can use cryptosporidiosis surveillance data to characterize the epidemiology of cryptosporidiosis in the United States, establish public health priorities (e.g., research) to improve cryptosporidiosis prevention and control, and design and evaluate efforts (e.g., health communication and policy) to prevent and control the transmission of Cryptosporidium.

Since 1978, CDC, the U.S. Environmental Protection Agency, and the Council of State and Territorial Epidemiologists have collaborated on the Waterborne Disease and Outbreak Surveillance System (WBDOSS) for collecting and reporting data on waterborne disease outbreaks associated with recreational water. This surveillance system is the primary source of data concerning the scope and health effects of waterborne disease outbreaks in the United States. In addition, data are collected on other select recreational water--associated health events, including pool chemical--associated health events and single cases of Vibrio wound infection and primary amebic meningoencephalitis (PAM).Data presented summarize recreational water--associated outbreaks and other health events that occurred during January 2007--December 2008. Previously unreported data on outbreaks that have occurred since 1978 also are presented.The WBDOSS database includes data on outbreaks associated with recreational water, drinking water, water not intended for drinking (excluding recreational water), and water use of unknown intent. Public health agencies in the states, the District of Columbia, U.S. territories, and Freely Associated States are primarily responsible for detecting and investigating waterborne disease outbreaks and voluntarily reporting them to CDC using a standard form. Only data on outbreaks associated with recreational water are summarized in this report. Data on other recreational water--associated health events reported to CDC, the Agency for Toxic Substances and Disease Registry (ATSDR), and the U.S. Consumer Product Safety Commission (CPSC) also are summarized.A total of 134 recreational water--associated outbreaks were reported by 38 states and Puerto Rico for 2007--2008. These outbreaks resulted in at least 13,966 cases. The median outbreak size was 11 cases (range: 2--5,697 cases). A total of 116 (86.6%) outbreaks were associated with treated recreational water (e.g., pools and interactive fountains) and resulted in 13,480 (96.5%) cases. Of the 134 outbreaks, 81 (60.4%) were outbreaks of acute gastrointestinal illness (AGI); 24 (17.9%) were outbreaks of dermatologic illnesses, conditions, or symptoms; and 17 (12.7%) were outbreaks of acute respiratory illness. Outbreaks of AGI resulted in 12,477 (89.3%) cases. The etiology was laboratory-confirmed for 105 (78.4%) of the 134 outbreaks. Of the 105 outbreaks with a laboratory-confirmed etiology, 68 (64.8%) were caused by parasites, 22 (21.0%) by bacteria, five (4.8%) by viruses, nine (8.6%) by chemicals or toxins, and one (1.0%) by multiple etiology types. Cryptosporidium was confirmed as the etiologic agent of 60 (44.8%) of 134 outbreaks, resulting in 12,154 (87.0%) cases; 58 (96.7%) of these outbreaks, resulting in a total of 12,137 (99.9%) cases, were associated with treated recreational water. A total of 32 pool chemical--associated health events that occurred in a public or residential setting were reported to WBDOSS by Maryland and Michigan. These events resulted in 48 cases of illness or injury; 26 (81.3%) events could be attributed at least partially to chemical handling errors (e.g., mixing incompatible chemicals). ATSDR's Hazardous Substance Emergency Events Surveillance System received 92 reports of hazardous substance events that occurred at aquatic facilities. More than half of these events (55 [59.8%]) involved injured persons; the most frequently reported primary contributing factor was human error. Estimates based on CPSC's National Electronic Injury Surveillance System (NEISS) data indicate that 4,574 (95% confidence interval [CI]: 2,703--6,446) emergency department (ED) visits attributable to pool chemical--associated injuries occurred in 2008; the most frequent diagnosis was poisoning (1,784 ED visits [95% CI: 585--2,984]). NEISS data indicate that pool chemical--associated health events occur frequently in residential settings. A total of 236 Vibrio wound infections were reported to be associated with recreational water exposure; 36 (48.6%) of the 74 hospitalized vibriosis patients and six (66.7%) of the nine vibriosis patients who died had V. vulnificus infections. Eight fatal cases of PAM occurred after exposure to warm untreated freshwater.The 134 recreational water--associated outbreaks reported for 2007--2008 represent a substantial increase over the 78 outbreaks reported for 2005--2006 and the largest number of outbreaks ever reported to WBDOSS for a 2-year period. Outbreaks, especially the largest ones, were most frequently associated with treated recreational water and characterized by AGI. Cryptosporidium remains the leading etiologic agent. Pool chemical--associated health events occur frequently but are preventable. Data on other select recreational water--associated health events further elucidate the epidemiology of U.S. waterborne disease by highlighting less frequently implicated types of recreational water (e.g., oceans) and detected types of recreational water--associated illness (i.e., not AGI).CDC uses waterborne disease outbreak surveillance data to 1) identify the types of etiologic agents, recreational water venues, and settings associated with waterborne disease outbreaks; 2) evaluate the adequacy of regulations and public awareness activities to promote healthy and safe swimming; and 3) establish public health priorities to improve prevention efforts, guidelines, and regulations at the local, state, and federal levels.

Subtyping was conducted in late 2007 on 57 Cryptosporidium specimens from sporadic cases in Colorado, Idaho, New Mexico, and Iowa. One previously rare Cryptosporidium hominis subtype was indentified in 40 cases (70%) from all four states, and the Cryptosporidium horse genotype was identified in a pet shop employee with severe clinical symptoms.

SUMMARYCryptosporidiumspecies have emerged as a major cause of outbreaks of diarrhoea and have been associated with consumption of contaminated recreational and drinking water and food as well as contact with infected attendees of child-care programmes. In August 2007, the Colorado Department of Public Health and Environment detected an increase in cryptosporidiosis cases over baseline values. We conducted a case-control study to assess risk factors for infection and collected stool specimens from ill persons for microscopy and molecular analysis. Laboratory-confirmed cases (n=47) were more likely to have swallowed untreated water from a lake, river, or stream [adjusted matched odds ratio (aOR) 8·0, 95% confidence interval (CI) 1·3–48·1], have had exposure to recreational water (aOR 4·6, 95% CI 1·4–14·6), or have had contact with a child in a child-care programme or in diapers (aOR 3·8, 95% CI 1·5–9·6). Although exposure to recreational water is commonly implicated in summertime cryptosporidiosis outbreaks, this study demonstrates that investigations of increased incidence of cases in summer should also examine other potential risk factors. This study emphasizes the need for public health education efforts that address the multiple transmission routes forCryptosporidiumand appropriate prevention measures to avoid future transmission.

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.

Since 1971, CDC, the U.S. Environmental Protection Agency, and the Council of State and Territorial Epidemiologists have collaboratively maintained the Waterborne Disease and Outbreak Surveillance System for collecting and reporting data related to waterborne-disease outbreaks (WBDOs) associated with drinking water. In 1978, WBDOs associated with recreational water (natural and treated water) were added. This system is the primary source of data regarding the scope and effects of disease associated with recreational water in the United States. In addition, data are collected on individual cases of recreational water-associated illnesses and infections and health events occurring at aquatic facilities but not directly related to water exposure.Data presented summarize WBDOs and case reports associated with recreational water use that occurred during January 2005--December 2006 and previously unreported disease reports and outbreaks during 1978--2004.Public health departments in the states, territories, localities, and the Freely Associated States (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) have primary responsibility for detecting, investigating, and voluntarily reporting WBDOs to CDC. Although the surveillance system includes data for WBDOs and cases associated with drinking water, recreational water, and water not intended for drinking, only cases and outbreaks associated with recreational water and health events at aquatic facilities are summarized in this report.During 2005--2006, a total of 78 WBDOs associated with recreational water were reported by 31 states. Illness occurred in 4,412 persons, resulting in 116 hospitalizations and five deaths. The median outbreak size was 13 persons (range: 2--2,307 persons). Of the 78 WBDOs, 48 (61.5%) were outbreaks of gastroenteritis that resulted from infectious agents or chemicals; 11 (14.1%) were outbreaks of acute respiratory illness; and 11 (14.1%) were outbreaks of dermatitis or other skin conditions. The remaining eight were outbreaks of leptospirosis (n = two), primary amebic meningoencephalitis (n = one), and mixed or other illnesses (n = five). WBDOs associated with gastroenteritis resulted in 4,015 (91.0%) of 4,412 illnesses. Fifty-eight (74.4%) WBDOs occurred at treated water venues, resulting in 4,167 (94.4%) cases of illness. The etiologic agent was confirmed in 62 (79.5%) of the 78 WBDOs, suspected in 12 (15.4%), and unidentified in four (5.1%). Thirty-four (43.6%) WBDOs had a parasitic etiology; 22 (28.2%), bacterial; four (5.1%), viral; and two (2.6%), chemical or toxin. Among the 48 gastroenteritis outbreaks, Cryptosporidium was confirmed as the causal agent in 31 (64.6%), and all except two of these outbreaks occurred in treated water venues where Cryptosporidium caused 82.9% (29/35) of the gastroenteritis outbreaks. Case reports associated with recreational water exposure that were discussed and analyzed separately from outbreaks include three fatal Naegleria cases and 189 Vibrio illnesses reported to the Cholera and Other Vibrio Illness Surveillance System. For Vibrio reporting, the most commonly reported species were Vibrio vulnificus, V. alginolyticus, and V. parahaemolyticus. V. vulnificus illnesses associated with recreational water exposure had the highest Vibrio illness hospitalization (77.6%) and mortality (22.4%) rates. In addition, 32 aquatic facility-related health events not associated with recreational water use (e.g., pool chemical mixing accidents) that occurred during 1983--2006 were received from New York. These events, which caused illness in 364 persons, are included in this report but analyzed separately.The number of WBDOs summarized in this report and the trends in recreational water-associated disease and outbreaks demonstrate a substantial increase in number of reports from previous years. Outbreaks, especially the largest ones, occurred more frequently in the summer at treated water venues and caused gastrointestinal illness. Deficiencies leading to WBDOs included problems with water-quality, venue design, usage, and maintenance. Case reports of illness associated with recreational water use expand our understanding of the scope of waterborne illness by further underscoring the contribution of less well-recognized swimming venues (e.g., oceans) and illness (e.g., nongastrointestinal illness). Aquatic facilities are also a focus for injuries involving chemicals or equipment used routinely in the operation of swimming venues, thus illustrating the lack of training of some aquatics staff.CDC uses WBDO surveillance data to 1) identify the etiologic agents, types of aquatic venues, water-treatment systems, and deficiencies associated with outbreaks and case reports; 2) evaluate the adequacy of efforts (i.e., regulations and public awareness activities) to provide safe recreational water; 3) expand the scope of understanding about waterborne disease and health events associated with swimming and aquatics facilities; and 4) establish public health prevention priorities, data, and messaging that might lead to improved regulations, guidelines, and prevention measures at the local, state, and federal levels.

Cryptosporidiosis, a gastrointestinal illness, is caused by protozoa of the genus Cryptosporidium.1999-2002.State and two metropolitan health departments voluntarily reported cases of cryptosporidiosis through CDC's National Electronic Telecommunications System for Surveillance.During 1999-2002, the total number of reported cases of cryptosporidiosis increased from 2,769 for 1999 to 3,787 for 2001 and then decreased to 3,016 for 2002. The number of states reporting cryptosporidiosis cases increased from 46 to 50, and the number of states reporting more than four cases per 100,000 population increased from two to five. A greater number of case reports were received for children aged 1-9 years and for adults aged 30-39 years compared with other age groups. Incidence of cryptosporidiosis was particularly high in the upper Midwest and Vermont. Peak onset of illness occurred annually during early summer through early fall.Transmission of cryptosporidiosis occurs throughout the United States, with increased diagnosis or reporting occurring in northern states. However, state incidence figures should be compared with caution because individual state surveillance systems have varying capabilities to detect cases. The seasonal peak in age-specific case reports coincides with the summer recreational water season and might reflect increased use of communal swimming venues (e.g., lakes, rivers, swimming pools, and water parks) by young children.Cryptosporidiosis surveillance provides data to educate public health practitioners and health-care providers about the epidemiologic characteristics and the disease burden of cryptosporidiosis in the United States. These data are used to improve reporting of cases, plan prevention efforts, and establish research priorities.

Giardiasis, a gastrointestinal illness, is caused by the protozoan parasite Giardia intestinalis.1998-2002.State, commonwealth, territorial, and two metropolitan health departments voluntarily reported cases of giardiasis through CDC's National Electronic Telecommunications System for Surveillance.During 1998-2002, the total number of reported cases of giardiasis decreased from 24,226 for 1998 to 19,708 for 2001 and then increased to 21,300 for 2002. The number of states reporting giardiasis cases increased from 42 to 46; however, the number of states reporting more than 15 cases per 100,000 population decreased from 10 to five. A greater number of case reports were received for children aged 1-9 years and for adults aged 30-39 years compared with other age groups. Incidence of giardiasis was highest in northern states. Peak onset of illness occurred annually during early summer through early fall.The increase observed for 2002 might reflect increased reporting after reporting of giardiasis as a nationally notifiable disease began in 2002. Transmission of giardiasis occurs throughout the United States, with increased diagnosis or reporting occurring in northern states. However, state incidence figures should be compared with caution because individual state surveillance systems have varying capabilities to detect cases. The seasonal peak in age-specific case reports coincides with the summer recreational water season and might reflect increased use of communal swimming venues (e.g., lakes, rivers, swimming pools, and water parks) by young children.Giardiasis surveillance provides data to educate public health practitioners and health-care providers about the epidemiologic characteristics and the disease burden of giardiasis in the United States. These data are used to improve reporting of cases, plan prevention efforts, and establish research priorities.

garding our article [2], and we appreciate the opportunity to respond. We agree that our wording was imprecise in the discussion of interpretation of the results of the ORs calculated in the multivariate analysis, and we agree that it is implausible that human Mycobacterium bovis tuberculosis (TB) is more likely than Mycobacterium tuberculosis TB, given that human M. bovis TB is much less prevalent than M. tuberculosis TB [1]. We interpreted the same statistics correctly and precisely in both the abstract and the results section of the document as: "Patients who were not born in the United States, Hispanic patients, patients

We linked an outbreak of cryptosporidiosis to ozonated apple cider by using molecular and epidemiologic methods. Because ozonation was insufficient in preventing this outbreak, its use in rendering apple cider safe for drinking is questioned.