Policy guidance on water-related disease surveillance

Policy guidance on waterrelated disease surveillance

ABSTRACT
Thepresentdocumentcontainsguidanceonthepolicyrelatedtowaterrelateddiseasesurveillancedevelopedby theTaskForceonWaterrelatedDiseaseSurveillanceestablishedundertheProtocolonWaterandHealthtothe 1992ConventiononProtectionandUseofTransboundaryWatersandInternationalLakes.Itwasadoptedbythe MeetingofthePartiesduringtheirsecondsession(BucharestRomania,23/25November2010). TheguidanceprovidesexplanationsonlegalobligationswithregardtodiseasesurveillanceundertheProtocol andotherinternationalframeworks,andoutlinespolicyadviceonhowtosetupandmaintainaneffectiveand efficientdiseasesurveillancesystem.Theseexplanationsarecoupledwithillustrativeexamplesofgoodpractices inthepanEuropeanRegion.

Keywords
ENVIRONMENTAL MONITORING methods EPIDEMIOLOGICAL SURVEILLANCE methods WATER POLLUTION prevention and control WATER MICROBIOLOGY DISEASE TRANSMISSION HEALTH POLICY GUIDELINES

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ISBN 978 92 890 0236 3 World Health Organization 2011 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Cover photo: iStockphoto

CONTENTS
1.THEPROBLEM....................................................................................................................................................... 1 2.WATERSAFETYPLANS .......................................................................................................................................... 2 3.LEGALOBLIGATIONS............................................................................................................................................. 3 3.1.ObligationsundertheProtocolonWaterandHealth .................................................................................. 3 3.2.SurveillanceandtheInternationalHealthRegulations(2005)..................................................................... 4 3.3.SurveillanceandtheacquiscommunautaireoftheEuropeanUnion........................................................... 5 4.SURVEILLANCESYSTEMFORWATERRELATEDDISEASE....................................................................................... 5 5.HOWTOSETUPASURVEILLANCESYSEMFORWATERRELATEDDISEASE ........................................................... 6 5.1.Locallevel ..................................................................................................................................................... 7 5.2.Regionallevel................................................................................................................................................ 8 5.3.Nationallevel................................................................................................................................................ 8 6.HOWAWATERRELATEDDISEASESURVEILLANCESYSTEMSHOULDWORKINPRACTICE.................................... 9 6.1.Preparedness ................................................................................................................................................ 9 6.2.Response..................................................................................................................................................... 10 7.HOWTOEVALUATEASURVEILLANCESYSTEMFORWATERRELATEDDISEASES................................................ 12 8.NATIONALEXAMPLES ......................................................................................................................................... 13 8.1.WaterrelateddiseasesurveillanceinArmenia .......................................................................................... 13 8.2.TheSlovakexperienceofintersectoralcollaborationinwaterprotectionandmanagement.................... 15 8.3.Norway:exampleofcomplementarityofwaterqualitymonitoringanddiseaseoutbreakdetection ...... 16 8.4.Croatia ........................................................................................................................................................ 17 8.5.Hungary ...................................................................................................................................................... 17 8.6.Germany ..................................................................................................................................................... 18 8.7.Finland:surveillanceofwaterborneoutbreaks .......................................................................................... 18 CONTRIBUTORS ...................................................................................................................................................... 21 DOCUMENTSUSEDFORTHEPREPARATIONOFTHEGUIDANCE ............................................................................ 22

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1.THEPROBLEM
Contaminateddrinkingwaterthathasnotundergoneadequatetreatmentcantransferseveral riskfactorstoconsumers,suchaspathogenicmicroorganisms,chemicalagentsincluding cyanotoxins,andradioactivesubstances. Waterrelateddiseasesremainamajorhealthconcernworldwide.Diarrhoealdiseasesaccount forsome2milliondeathseachyear,primarilyofchildrenindevelopingcountries.Theyare responsiblefor17%ofdeathsinchildrenunder5yearsofage,withanestimatedmedianof3.2 episodesperchildperyear.Atotalof94%ofthisdiseaseburdenisconsideredtobeattributable totheenvironment,whichincludesunsafewater,lackofsanitationandpoorhygiene. Moreover,severeoutbreaksofdiseasessuchascholera,typhoidfeverandhepatitisAcanbe transmittedthroughfaecallycontaminateddrinkingwater. Muchattentionhasbeenfocusedonthedetectionandinvestigationofoutbreaksofwaterborne disease.Itislikelythatmostillnessescausedbycontaminatedwaterwillnotbepartofan obviousoutbreak.Identifyingtheseillnessesasbeingduetowaterismoreproblematic.Most surveillancesystemsfordiarrhoealdiseasewillnotbeabletodistinguishthoseillnesses acquiredfromwaterfromthoseacquiredfromothersources. Furthermore,theissueofemergingpathogenshasbecomeamajorconcerninrecentyears. Emergingpathogenscomprisedifferentgroupsofmicroorganisms:thosethathavebeennewly detected(forexample,forwaterrelatedpathogens:Cryptosporidiumparvum,Legionella pneumophila);thosewhosepathogenicmutantshavebeennewlydetected (enterohaemorrhagicEscherichiacoli);thosethathavebeennewlyidentifiedasthecauseofa wellknowninfectiousdisease(hepatitisEvirus);andthosewhoseassociationwithawellknown malignantordegenerativediseasehasbeennewlydetected(Helicobacterpylori).Theincrease inwaterrelateddiseasescausedbyemergingpathogensisassociatedwiththegrowing numbersofpeoplewithreducedimmunocompetence,anincreaseinpopulationage (demographictransition)andmobility,andnewandcomplextechnicalapplicationsofwater,for example,dentalunits,airconditioning,coolingtowersandspas. Drinkingwaterrelatedoutbreaksoftencausethesimultaneousinfectionofalargenumberof consumers,whomayrepresentasubstantialproportionofacommunity. Surfacewaterusedfordrinkinggenerallyrepresentsthemajorvehicleofhumandisease transmission.Incontrasttogroundwater,surfacewatercanbemoreeasilycontaminatedby animalhusbandry,pasturefarming,sewagedischargeandthedisposalofdangeroussubstances. WithintheWHOEuropeanRegiontherearecleardifferencesbetweenthedifferent geographicalareasintheburdensofmortalityandmorbidityattributabletooutbreaksofwater relateddiseases. Over30millioncasesofwaterrelateddiseaseoutbreakscouldbeavoidedannuallybymeansof adequatewaterandsanitationinterventions.Investinginwatersupplyandsanitationhas producedbenefitsfargreaterthanthosedirectlyrelatedtothecostoftreatmentforthese humanpathologies.

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Fromahumanhealthpointofview,thechemicalcontaminationofdrinkingwaterisgenerallyof muchlessimportancethanmicrobiologicalcontamination.Nevertheless,insomesituations, somechemicals(forexample,nitrate,fluoride,arsenic)canreachparticularlyhigh concentrationsandcanconstituteanissueofpublicconcern. Surveyingthehealthstatusofcommunitiesandpromotingadequatepreventivemeasuresare twomainandcomplementarytoolsthatcanbesuccessfullyappliedtoensureadequatequality andquantityofwaterneededtoensureandfosterhumanhealth.

2.WATERSAFETYPLANS
Theriskassessment/riskmanagementmethodrecommendedinthethirdeditionoftheWHO guidelinesfordrinkingwaterquality(WHO,2004)tomanagerisksfromsourcetotapisknown asawatersafetyplan(WSP).Experiencegainedinassessing,managingandpreventingsuch riskstohealthcanbesuccessfullyusedtoreduceandminimizetheburdenofwaterrelated diseases.Itiswellknownthat: (a)rawwatersshouldbeprotectedagainstpollutioninthecatchmentarea; (b)surfaceandshallowwatersmustalwaysbetreatedbeforebeingusedasa sourceofdrinkingwater,whilegroundwaterfromdeepwellsshouldbetreated onlywhencontaminated;thehigherthelevelofcontaminationofrawwater,the greatertherequiredefficiencyofthewatertreatmentprocess; (c)drinkingwatershouldbesubjecttosurveillanceforthemainriskfactors,with specialattentiontomicrobialquality;chemicalqualitymustalsobeincludedinthe surveillance; (d)thepersonnelresponsibleforsafedrinkingwaterdistributionandmonitoring systemsshouldreceiveadequateeducationandtraining. Inthiscontext,oneofthemostimportanttoolsforensuringsafewateristheWHOWSP;a managementapproachthatemphasizespreventionorreductionofcontaminationofwater sourcesanddecreasesrelianceontreatmentprocessesfortheremovalofcontamination.WSPs shouldbedevelopedforeachindividualdrinkingwatersystem,whetherlargeorsmallscale. ThekeystepsofaWSPareasfollows: (a)assembletheteamtopreparetheWSP; (b)documentanddescribethewatersupplyarea; (c)undertakeahazardassessmentandriskcharacterizationtoidentifyhowhazards canenterintothewatersupply; (d)assesstheexistingorproposedsystem,includingadescriptionofthesystem andaflowdiagram; (e)identifycontrolmeasurestoreduceandmanagetherisks; (f)definehowcontrolmeasuresaretobemonitoredtoensureacceptable performanceoftheWSP;

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(g)establishprocedurestoverifythattheWSPisworkingeffectivelyandwillmeet therelevanthealthbasedtargets; (h)developsupportingprogrammes,alongwithtraining,hygienepractices, standardoperatingprocedures,upgradingandimprovement,andresearchand development; (i)preparemanagementprocedures,includingcorrectiveactions,bothfornormal andincidentconditions; (j)establishdocumentationandcommunicationprocedures;thesecanhavea significantimpactontheefficacyofcertainremovalprocesses; (k)reviewperiodicallyeachWSP. WSPsshouldbereviewedandagreedoninconsultationwiththeauthorityresponsiblefor protectionofpublichealthtoensurethattheywilldeliverwaterofaqualityconsistentwith healthbasedtargets.

3.LEGALOBLIGATIONS
3.1.ObligationsundertheProtocolonWaterandHealth PartiestotheProtocolonWaterandHealthhaveanumberofobligationsconcerningthe surveillanceofwaterrelateddiseases. Article6,paragraph2oftheProtocolstates:
Forthesepurposes,thePartiesshalleachestablishandpublishnationaland/orlocaltargets forthestandardsandlevelsofperformancethatneedtobeachievedormaintainedfora highlevelofprotectionagainstwaterrelateddisease.Thesetargetsshallbeperiodically revised.Indoingallthis,theyshallmakeappropriatepracticaland/orotherprovisionsfor publicparticipation,withinatransparentandfairframework,andshallensurethatdue accountistakenoftheoutcomeofpublicparticipation.Exceptwherenationalandorlocal circumstancesmakethemirrelevantforpreventing,controllingandreducingwaterrelated diseases,thetargetsshallcover,interalia: (a)Thequalityofthedrinkingwatersupplied,takingintoaccounttheWHOsguidelinesfor drinkingwaterquality(WHO,2004); (b)Thereductionofthescaleofoutbreaksandincidentsofwaterrelateddisease.

Accordingtoarticle6,paragraph3,withintwoyearsofbecomingaParty,eachPartyshall establishandpublishtargetsreferredtoinparagraph2ofthisarticle,andtargetdatesfor achievingthem. Inadditiontoroutinesurveillance,theProtocolalsomakesspecificprovisionsforresponse systemsunderarticle8. 1.ThePartiesshalleach,asappropriate,ensurethat:

(a)comprehensivenationaland/orlocalsurveillanceandearlywarningsystemsare established,improvedormaintainedwhichwill: (i)identifyoutbreaksorincidentsofwaterrelateddiseaseorsignificantthreats

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ofsuchoutbreaksorincidents,includingthoseresultingfromwaterpollution incidentsorextremeweatherevents; (ii)givepromptandclearnotificationtotherelevantpublicauthoritiesregarding suchoutbreaks,incidentsorthreats; (iii)intheeventofanyimminentthreattopublichealthfromwaterrelateddisease, disseminatetomembersofthepublicwhomaybeaffectedallinformationthatis heldbyapublicauthorityandthatcouldhelpthepublictopreventormitigateharm; (iv)makerecommendationstotherelevantpublicauthoritiesand,where appropriate,tothepublicregardingpreventiveandremedialactions; (b)comprehensivenationalandlocalcontingencyplansforresponsestosuchoutbreaks, incidentsandrisksareproperlypreparedinduetime; (c)therelevantpublicauthoritieshavethenecessarycapacitytorespondtosuchoutbreaks, incidentsorrisksinaccordancewiththerelevantcontingencyplan. 2.Surveillanceandearlywarningsystems,contingencyplansandresponsecapacityinrelationto waterrelateddiseasemaybecombinedwiththoseinrelationtoothermatters. 3.WithinthreeyearsofbecomingaParty,eachPartyshallhaveestablishedsurveillanceandearly warningsystems,contingencyplansandresponsecapacitiesreferredtoinparagraph1ofthis article.

3.2.SurveillanceandtheInternationalHealthRegulations(2005) TheInternationalHealthRegulations 1 areaninternationallegalinstrumentthatisbindingon 194countriesacrosstheglobe,includingalltheMemberStatesofWHO.Theiraimistohelpthe internationalcommunitytopreventandrespondtoacutepublichealthrisksthathavethe potentialtocrossbordersandthreatenpeopleworldwide.TheRegulationsenteredintoforce on15June2007. TheRegulationsrequireeachStatePartytodevelop,strengthenandmaintaincorenational publichealthcapacitiesattheprimary,intermediateandnationallevelsinordertodetect, assess,notifyandreporteventsandtorespondpromptlyandeffectivelytopublichealthrisks andemergencies.Afundamentalinnovationinthenewlegalpublichealthframeworkisthe mandatoryobligationforallStatePartiestodevelop,strengthenandmaintaincorepublic healthcapacitiesforsurveillanceandresponseassoonaspossible.TheRegulationssetouta twophaseprocesstoassistStatesPartiestoplanfortheimplementationoftheircapacity strengtheningobligations. Phase1covered:15June2007to15June2009 By15June2009,StatePartieshadtoassesstheabilityoftheirexistingnationalpublichealth structuresandresourcestomeetthecoresurveillanceandresponsecapacityrequirements describedinAnnex1AoftheRegulations.Followingthisassessment,StatePartieswererequired todevelopnationalactionplanstoensurethatthesecorecapacitiesexistedandwere
1

Forfurtherinformation,seetheWHOwebpagesdealingwiththeInternationalHealthRegulations (http://www.who.int/ihr/en/,accessed6April2010).

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functioningproperlythroughoutthecountry.WHOsupportssuchassessmentsandprovides guidanceonthecontentandstructureofnationalplans. Phase2covers15June2009to15June2012 By15June2012,thesurveillanceandresponsecapacitiessetoutinAnnex1AoftheRegulations areexpectedtobeimplementedbyeachStateParty.StatePartiesthatexperiencedifficultiesin implementingtheirnationalplansmayrequestanadditionaltwoyearperioduntil15June2014 tomeettheirAnnex1Aobligations.Inexceptionalcircumstances,theDirectorGeneralmay grantanindividualStatePartyafurthertwoyears,until15June2016,tomeettheirobligations. 3.3.SurveillanceandtheacquiscommunautaireoftheEuropeanUnion EpidemiologicalsurveillanceintheEuropeanUnion(EU)isbasedonDecision2119/98/ECofthe EuropeanParliamentandoftheCouncilof24September1998,settingupanetworkforthe epidemiologicalsurveillanceandcontrolofcommunicablediseasesintheCommunity,nowthe EU.TheDecisionenteredintoforceon3January1999. CommissionDecision2000/96/ECof22December1999onthecommunicablediseasestobe progressivelycoveredbytheCommunitynetworkunderDecision2119/98/ECoftheEuropean ParliamentandoftheCouncil(notifiedunderDocumentC(1999)4015)listsinAnnex1the communicablediseasesandspecialhealthissuestobecovered.Theseinclude,interalia,viral hepatitisA,foodborneandwaterbornediseasesofenvironmentalorigin(campylobacteriosis, cryptosporidiosis,giardiasis,infectionswithenterohaemorrhagicE.coli,shigellosisandothers) andseriousimporteddiseases(cholera,malaria).TheHealthSurveillanceSystemfor CommunicableDiseaseswithintheEuropeanPublicHealthInformationNetwork(Euphin HSSCD)isidentifiedastheinterimtechnicalimplementationmechanism.Decision2000/96/EC tookeffecton1January2000. CommissionDecision2002/253/ECdated19March2002providesdefinitionsforreporting communicablediseasestotheCommunitynetworkunderDecision2119/98/ECoftheEuropean ParliamentandoftheCouncil.ThisDecisionmakesreportingmandatoryforanumberof diseases,including,interalia,campylobacteriosis,cholera,cryptosporidiosis, enterohaemorrhagicE.coliinfections,giardiasis,viralhepatitisA,legionellosis,malaria, salmonellosis,shigellosisandtyphoidandparatyphoidfever.Informationoncurrentnational effortsindiseasereportingiscoordinatedthroughtheInventoryofResourcesforInfectious DiseasesinEurope.Decision2002/253/ECappliedasof1January2003.

4.SURVEILLANCESYSTEMFORWATERRELATEDDISEASE
Surveillance systems for the main communicable diseases have been established and implementedinalmostallthecountriesintheWHOEuropeanRegion.However,theyoftendo notincludespecificsurveillanceforwaterrelateddiseases.Specificsurveillancesystemstailored towaterrelateddiseaseswouldproviderelevantaddedvalue,astheycan: (a)identifythediseasestransmittedbywater(theseareusuallynotwellidentified throughthecurrentsurveillancesystems); (b)defineorestimatetheburdenofwaterrelateddiseases;

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(c)usedataandinformationtoidentifycommunitiesinwhichthereareproblems withwaterrelateddiseases(mappingofpollutionhazardsandidentifyingrisksmay beparticularlyuseful); (d)promoteinterventionmeasurestocontrolandpreventwaterrelateddiseases; (e)targetresourcestowardsareaswithpriorityneeds; (f)assesstheeffectivenessoftheimplementedwaterandsanitationinterventions inreducingdiseases. Surveillancesystemsforwaterrelateddiseasescanbeespeciallyusefulincountrieswithlimited resources,whereinterventionsshouldbedesignedtobefeasible,effectiveandeconomical. Examplesaregivenhere. (a)Informationontheincidenceoftyphoidfevermayindicatetheneedfor targetedimmunizationcampaignsinspecificgeographiclocations. (b)Informationonepidemicandendemicgiardiasisandcryptosporidiosisin communitiesthatusesurfacewatersuppliesmayindicatetheneedforwater filtrationprocessesbecausechlorinationisnotveryeffectiveagainstthese pathogens.However,notallcountrieshavethecapacitytodetectcryptosporidiosis andgiardiasisintheirlaboratories.Laboratorystrengtheningintheareaofchlorine resistancepathogendetectionisurgentlyneeded,asisadviceonhouseholdwater treatmentinhighriskareas. (c)Informationonoutbreaksofawaterbornediseaseinadequatelytreatedpiped watersuppliesmayindicateintrusionproblemsinthewaterdistributionsystem andtheneedtokeepwaterpressurestableoracceptadditionalmeasures,suchas boosterchlorinationsystemsinthedistributionsystemoradditionalwater treatmentatthehouseholdlevel;informationshowingahighprevalenceof helminthinfectionsmaysuggesttheneedforimprovementsinsanitationand increasedwateravailabilityforgeneralhygiene. (d)Informationontheincidenceofbluebabysyndromeinanareamayindicatethe needtocontrolandreducenitrateconcentrationsindrinkingwater.

5.HOWTOSETUPASURVEILLANCESYSEMFORWATERRELATED DISEASE
Publichealthsurveillancesystemsrepresenttheongoingandsystematiccollection,analysisand interpretationofhealthdatatodescribeandmonitorahealthevent. Thesurveillanceofwaterrelateddiseasesshouldbeincludedwithinthecontextofmore generalsurveillancesystemsforcommunicablediseases.Aspecificsurveillancesystemfor waterbornediseaseoutbreaksshouldincludeamethodforevaluatingtheevidencethatan outbreakisindeedattributabletocontaminatedwater. Severalapproachescanbeusedtoestablishwaterbornediseasesurveillancesystems, dependingonthedatatobecollected,howquicklytheyneedtobecollectedandanalysedand thehumanandfinancialresourcesavailable.

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Awidespectrumofpossiblehealthoutcomesrangingfromasymptomaticinfections,specific symptomsanddiseases,todeathcanbecoveredbythesurveillancesystem. AccordingtothefirstmeetingofthePartiestotheProtocolonWaterandHealth(Geneva, Switzerland,1719January2007),waterrelateddiseasescanbedefinedasprioritydiseases whentheyarecharacterizedbyahighepidemicpotential,asinthecaseofcholera,diseases causedbyenterohaemorrhagicE.coli,viralhepatitisA,bacillarydysenteryandtyphoidfever. Emergingdiseasesarethoseshowingarapidincreaseintheaffectedpopulation,orwhichare beingobservedincountriesinwhichtheywerepreviouslyabsent.Theyinclude campylobacteriosis,cryptosporidiosis,giardiasisandlegionellosis. Localdiseasesarethosethatarenotpresentthroughoutthecountryconcernedbutmay potentiallyhaveaseverelocalimpact.Theyincludemethemoglobinaemia,arsenicosis,viral infections(particularlythoseattributabletonorovirus)andparasiticdiseases. Thesurveillancesystemcanfocusonthedetectionofindividualcases,orofoutbreaks;itcan monitorbroadcategoriesofhealthoutcomes,suchasdiarrhoealdiseases,orafewspecific pathogenssuchastyphoidfever,hepatitis,choleraorlegionellosis. Surveillancedatashouldbecollected,analysedandinterpreted.Publichealthauthoritiesshould beinformedtoallowthentotakeappropriateaction.Inmostsurveillancesystems,information iscollectedatthelocallevelandsenttoregionalandnationalhealthauthorities,whichcompile andanalysethedata.Theresultsofthedataanalysesarethensummarizedinreportsthatare providedtothenationalandlocalhealthauthorities.Insomecountries,thesereportsarealso madeavailabletothepublicandtointernationalagencies,suchasWHOandnongovernmental organizations(NGOs).Datacollectorsmustunderstandthepurposeofthesurveillancesystem, becommittedtoitsgoalsandseeevidencethattheinformationisusedtoimprovepublic health. 5.1.Locallevel Anoutbreakmanagementteamshouldbesetupatthelocalhealthunit,headedbyapublic healthofficerreportingtothelocaldirectorofpublichealth.Theoutbreakmanagementteam shouldbecomposedofrepresentativesofthewaterworksandsanitationsystem,thewater departmentoftheregionalenvironmentalagencyandanexpertinhygieneandenvironmental medicine. Incaseofanoutbreakofwaterrelateddisease,thelocaloutbreakmanagementteamshould: (a)reviewtheevidenceforanoutbreak (b)identifythepopulationatrisk (c)decideoncontrolmeasures (d)providequickandadequateinformationtothepublic (e)makearrangementsforthecommitmentofpersonnelandresources. Aclearwayforwardistolinkroutinehealthsurveillancedatawithdataonthequalityand distributionofwatersuppliesinthesamearea.Therehavebeenanumberofexamplesonhow thiscanworkinpractice,including:

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(a)theuseofgeographicalinformationsystemstomapthedistributionofcasesof illnessinrelationtothegeographicalboundariesofdifferentwatersystemsin ordertodeterminewhetherillnessratesaregreaterinpeopledrinkingfromone watersourcecomparedwithothers; (b)timeseriesanalysis,wherebyreportsofillnessarelinkedtodatafromroutine waterqualitymeasurementstodeterminewhetherillnessratesincreaseafter deteriorationinwaterqualityresults; (c)prospectivestudiesandenhancedsurveillanceinareasknowntohavepoorer qualitydrinkingwater. Thekeyissueistobeabletobringtogetherwaterandhealthdata.Inmanycountries,different governmentministriesareresponsibleforhealthsurveillanceandwaterqualitymonitoring. Sometimes,communicationbetweenthemmaynotbeideal.Nationalgovernmentsshould encouragethesharingofrelevantdatabetweentheiragenciesorministriesresponsiblefor healthsurveillanceandwatersafetymonitoring. 5.2.Regionallevel Anoutbreakmanagementteamwithsimilarfeaturesshouldbeestablishedattheregionallevel, toperformthefollowingtasksafteroutbreaksofwaterrelateddisease. (a)Prepareanotificationtobesenttothenationalagencies. (b)Prepareareporttobesenttotheregionalauthoritiesresponsibleformanagement measures. (c)Promotefurtherepidemiologicalandenvironmentalstudies,asnecessary. (d)Provideadequateinformationtothepublic. (e)Providefeedbackonsurveillanceresultsandanalysestothelocaloutbreak managementteaminordertosustaintheinterestandcooperationofthedatacollectors anddataproviders. 5.3.Nationallevel Anoutbreakmanagementteamatthenationallevelshouldbecomposedofrepresentatives fromthefollowingsectors:health,environment,waterworksandsanitation,aswellas agriculture,includinganimalhusbandryandaquaculture.Theoutbreakmanagementteam,led byahealthofficer,shouldaccomplishthefollowingtasks. (a)Draftnotificationsonwaterrelateddiseasesandprovideinformationtothe public. (b)Mapwaterrelateddiseasesonanationalscale,possiblyusinggeographic informationsystems. (c)Identifymostcriticalareasorsituations. (d)Assesstheburdenofwaterrelateddiseases. (e)Transmittheinformationonwaterrelateddiseasestotherelevantactorsatthe internationallevel.

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(f)Providetrainingandeducationalinitiatives. (g)Promotespecificsurveys. (h)Providefeedbackonsurveillanceresultsandanalysestotheregionaloutbreak managementteamsinordertosustaininterestandcooperation. (i)Assessthefunctionalityofthewholesurveillancesystem. (j)Prepareareporttobesenttothenationalauthoritiesresponsiblefor managementmeasures. (k)Coordinateactivitiesinthecaseoftransboundarywaterbodies.

6.HOWAWATERRELATEDDISEASESURVEILLANCESYSTEMSHOULD WORKINPRACTICE
6.1.Preparedness Firstandforemost,thelocaloutbreakmanagementteamshouldbewellpreparedtodetect waterrelatedoutbreaksandreactadequatelywhensuchanoutbreakoccurs. Theoutbreakmanagementteamshouldmeetregularlytobuilduptrustandreduce communicationbarriers.Rulesonalternaterepresentationshouldbeestablishedatthe beginningoftheprocesstoensurethatrepresentativesofeachrelevantinstitutionarealways available. Insettingupasurveillancesystem,itiscrucialtotakeintoaccountthelocalsituationandfocus oncriticalareasorsituations.Forexample,ruralandpoorerpopulationgroupsarelesslikelyto beincludedinasurveillancesystembecauseoftheirlimitedaccesstomedicalcare.Sometimes, alternativeactivesurveillanceapproachesmustbeusedtocapturethetruediseaseburdenin thesepopulations.Surveillancesystemsforwaterbornediseaseoutbreaksaremorelikelyto detectlargeroutbreaksthatoccurinlargemunicipalwatersystemsbecausemorepeopleare likelytobeaffectedandtheyhavebetteraccesstomedicalcareanddiagnosticlaboratoriesthat candetectandreporttheillness. Smallerwaterutilitiesmaybeatgreaterriskofproblemsrelatingtowaterbornedisease becausewaterqualityatthesefacilitiesmaybemonitoredlessfrequently,thefacilitiesmay havefewertreatmentprocessesandtheoperatorsmayhavelesstrainingandmayonlyworkon aparttimebasis.However,itismoredifficulttodetectwaterbornediseaseoutbreaks associatedwithsmallwaterutilitiesbecausefewerpeoplemaybeaffected,accesstomedical caremaybelimitedandtheremaybelittlecommunicationwithregionalornationalhealth authorities. However,sometimessmalloutbreaksinsmallcommunitiesforexample,when20outof40 elderlypeopleinnursinghomesbecomeillcanbemoreeasilyrecognizedthanbigoutbreaks inlargercommunities(forexample,anoutbreakofcryptosporidiosisinMilwaukeein1993was recognizedwhensome200000peoplewerealreadyill;thatis,halfofthepopulationhadbeen affectedbytheoutbreak).

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6.2.Response Theresponsephaseofanoutbreakmanagementapproachcanbedividedintothefollowing steps: (a)triggerevent:outbreakdetectionandconfirmation; (b)acutereaction:outbreakdeclaration,quickandpreliminarydescriptivehazard investigation,initialandimmediatecontrolmeasures; (c)analysis:indepthanalyticalhazardinvestigation,continuousreevaluationof controlmeasures; (d)normalization:conclusionofoutbreakanddeclarationofnormalization; (e)end:evaluation,formalreport,lessonslearnedforthefuture. Thetermtriggereventcoversawiderangeofsituationsrepresented,forexample: (a)anincreaseinthenumberofcasesofaparticular,potentiallywaterrelated diseasebeingreportedthroughthesurveillancesystem(localmedicaldoctorsand hospitalsmaycommunicatethisinformation); (b)adrinkingwatersampleexceedingmicrobiologicalorchemicallimits;this shouldalwaysraisethealarmandshouldpromptimmediateaction(local laboratoriesshouldprovideinformation); (c)relevanttechnicalfailuresinwatertreatmentordistributionfacilities,givingrise tofailureinthewatertreatmentprocess(waterworksshouldgivenotificationof suchevents); (d)unusualeventsinthecatchmentarea,suchasatransportaccident,extreme rainfallandrunoff,flooding,sewageorliquidmanureaccidents(environment agenciesandwaterworksshouldprovideinformation); (e)clustersofcustomerscomplaintsfromonesupplyzoneconcerningchangesin organolepticqualityoftapwater(waterworksshouldprovideinformation). Furthermore,pharmaciesshouldprovideinformationonhigherusagelevelsofspecificdrugs, andschoolsandworkplacesshouldprovidenotificationwhenanunusuallyhighnumberof absencesisnoticed. Intheacutereaction,anytriggereventshouldpromptanimmediatefirstmeetingofthe outbreakmanagementteam.Theteamshouldusedescriptiveepidemiologicaltechniquesto summarizekeyinformationregardingthepeopleaffectedandtheirillness.Who?When? Where?Aninitialcasedefinitionmustbeformulated.Thisisbasedonthedisease(clinical symptoms,laboratoryresults),thetimeperiodfordatesofonsetandageographicallocator. Themainoutcomesofthedescriptivestudyareanepidemiccurveandanepidemicmap depictingtheimportantinformationrelatingtotimeandplace.Basedonthisinformation,the epidemiologicalriskmustbeassessedandahypothesisonthecausesoftheoutbreakmustbe generated.Thelatterisimportantforbothimplementingcontrolmeasuresanddesigningan analyticalstudy.

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Inthecaseofflooding,allpotentialhealtheffectsshouldbetakenintoaccount:directhealth effects,includingdrowning,injuries,diarrhoea,vectorbornediseases(includingthosecarried byhouseholdpests),respiratoryinfections,skinandeyeinfectionsandmentalhealthproblems; aswellasotherindirecteffects,suchasdamagetohealthandwaterinfrastructures, contaminationofthefoodchain,destructionofshelterandpopulationdisplacement. Themajorgoalofthisphaseistoreducetheriskbyquicklyimplementingpreliminarycontrol measures.Treatmentfailuresmustbecorrected;insomecases,anadditionaldisinfectionstep mayhelp.Sometimesanalternativewatersupplyneedstobeactivated.Highriskindividuals shouldbeexcludedfromwaterconsumption(itisadvisabletohaveidentifiedthoseindividuals andinstitutionsinadvance)andconsumersmayadequatelyapplyhouseholdtreatmentsbefore consumingit. Informationshouldbegiventothepublicbyonlyoneperson,authorizedbytheoutbreak managementteam;itisclearlyadvantageoustohavearelevantprofessionalassumethis position. Theindepthanalysisofthesituationisbasedontwoapproaches,detailedhere. (a)Differentanalyticalepidemiologicalandsanitarystudiescanbeusedfortherisk assessmentofwaterrelateddiseaseoutbreaks:ecological,timeseries,case control,retrospectivecohort,interventionandseroprevalencestudies. (b)Adetailedhygienicecologicalsiteinspectionincludingcatchmentarea, treatmentplantanddistributionnetmayleadtoimportanthypothesesconcerning thecausesofanoutbreak.Mappingisthecentralmethodforthisapproach, supportedbytheresultsofwateranalysisinstandardchemicalandmicrobiological parametersfromthesamplesofrawwater,treatedwater,disinfectedwaterand waterfromtheconsumerstap. Duringtheanalyticalphase,thefurtherdevelopmentoftheoutbreaksituationshouldbe checkedcritically.Donewcasesoccur?Istheincidenceofcasesincreasingordecreasing?Are morbiditylevelsstagnatingordecreasing?Theimmediatecontrolmeasuresmustbe continuouslyrevaluated.Recommendationsforlongtermcontrolmeasuresshouldbegiven. Theanalysisshouldalsoconcernitselfwithlongertermeffectssuchasthetypeof contaminationofthepollutionofthewaterresource,thedurationofthecontaminationevent, theseasonalcharacteristicsofthetimeatwhichthecontaminationoccurred,newchallengesin wastemanagementandthepersonalhygieneconditionsofthepopulation. Beforenormalizationofthesituationcanbedeclared,thefollowingquestionsshouldbe answered. (a)Arethecausesoftheoutbreakcompletelyunderstood? (b)Haveefficientcontrolmeasuresbeenimplemented? (c)Withrespecttotheincubationperiod,donewcasesoccur? (d)Havewatersampleresultsmetmicrobiologicalorchemicalrequirementsforat leastthreedays?

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Finally,theoutbreakmanagementteamformallydeclarestheendoftheoutbreaktothepublic. Itsworkhasbeencompletedonceaformaloutbreakreporthasbeenwritten.Theefficiencyof incidencemanagementhastobeevaluated.Whatworked?Whatcouldhavebeendonebetter? Whatlessonscanbelearnedfrompastmistakes?Additionally,thecostsoftheoutbreakshould beassessedtogivedecisionmakersanideaofwhatsavingscouldbemadeifadequate preventivemeasuresweretobeinstalled.Finally,lessonslearnedshouldbeidentifiedinorder topreventoratleasttobettermanagefutureoutbreaks.

7.HOWTOEVALUATEASURVEILLANCESYSTEMFORWATERRELATED DISEASES
Theoutputofasurveillancesystemcanbemainlyevaluatedagainstthefollowingcriteria: sensitivity,timeliness,representativenessanddataquality.Thesensitivityofasystemisits abilitytodetecttheeventsundersurveillance.Asurveillancesystemshouldbesensitiveenough todetectnotonlychangesindiseaseincidence,butalsoahighcontinuouslevelofsporadic cases.Thetimelinessofawaterbornediseasesurveillancesystemcanbeassessedbymeasuring howlongittakesforacaseofwaterbornediseaseoranoutbreakofwaterbornediseasetobe recognizedandreportedtothesystem.Thedatacollectedinasurveillancesystemshouldbe representativeofthetruesituationinthepopulationcoveredbythesurveillancesystem. Assessmentsofdataqualityinaccordancewithinternationalnormscanbecarriedoutinorder toverifywhetherdatacollectedinthesystemarecompleteandaccurate. Mostpeoplewithoutaccesstoanimprovedwatersourceliveinruralareas(sixoutofseven).At thegloballevel,1.1billionpeoplelackaccesstowater.Ruralcommunitiesbothindeveloping anddevelopedcountriesarethemostaffectedbywaterbornediseaseoutbreaks.Providing safeandreliablewaterservicestothesepeopleisanessentiallongtermgoalthatwillyield healthandeconomicbenefits. Establishingspecificwatersurveillancesystemsinruralareascanstronglydecreasediarrhoea relatedmorbidityandmortality,aswellasotherwaterrelateddiseases,ifaccompaniedby relevantwatersupplymeasures. Asarule,alocalbodyisresponsibleformanagingthisissueinruralareas.Forexample,alocal outbreakmanagementteamshouldbeorganizedaccordingtotheabovementionedsetupand taskallocation.Thesebodiesshouldalsotakeresponsibilityforimplementingthemain componentsoftheWSPstoensurethatdrinkingwaterisofadequatequality. Outbreakmanagementteamsshouldalsocarryoutthefollowingtasks,iftheyarenotalready theresponsibilityofotheragencies,suchasthelocalpublichealthauthority. (a)Raiseawarenessamongtheruralpopulationregardingwaterqualityissuesand relatedwaterbornediseases. (b)Buildthecapacityofhealthfacilitiestoperformfieldtestsusingsimplifiedkits and,inparticular,tomaintainthemanagerialresponsibilityintheirrespectivearea. (c)Establishwatertestinglaboratoriesinselectedcriticalservices,suchasschools andruralhospitals.

Policy guidance on water-related disease surveillance page 13

(d)Takeimmediatecorrectiveactionwhenwatersamplesarefoundtobe contaminated. (e)Selectadequatesourcesofdrinkingwatersupplythatcomplywithwaterquality targets,suchasthosedefinedintheWHOguidelinesfordrinkingwaterquality (WHO,2004). (f)Trainoperatorstoensurethemostsuitable,continuousandadequatetreatment ofrawwaters. Manystudiesindicateadecrementindiarrhoealepisodesby39%bymeansofhouseholdwater treatmentandsafestorage.Hence,importantresultscanbeachievedinpreventingwaterborne diseasethroughthefollowinghouseholdinterventions. (a)Boilingisbyfarthemostcommonlyusedapproachtodisinfectwateratthe householdlevel. (b)Pointofusedisinfectionaddingchlorineinliquidortabletformtodrinking waterstoredinaprotectedcontainercanbealowcostoption. (c)Waterfiltrationisanothermeanstopurifywater;waterpurificationwith ceramicfiltersoftencoatedwithsilvertocontrolbacterialgrowthiseffectivein removingmanymicrobesandothersuspendedsolidsandalsomakeswater aestheticallyacceptableforconsumers. (d)Solardisinfectionexposeswaterindisposableclearplasticbottlestosunlightfor aday,typicallyontheroofofahouse. (e)Acombinedapproach,usingpowdersortabletstocoagulateandflocculate sedimentsinwaterfollowedbyatimedreleaseofdisinfectantisparticularly usefulfortreatingturbidwater. However,watertreatmentalsoneedstobeaccompaniedbysafestorage.Thiscanbe accomplishedbyusingcontainerswithnarrowopeningsandadispensingdevice,suchasatap orspigot,toprotectcollectedwateragainstcontamination.Thesemeasuresareparticularly importantbecausethemicrobialqualityofdrinkingwaterfrequentlydeclinesaftercollection. Finally,significanthealthbenefitscanbeachievedthroughhygieneeducation.

8.NATIONALEXAMPLES
Thefollowingsubsectionsillustratetheguidance,withexamplestakenfromcountriesthat participatedintheworkofthesubsidiarybodiesestablishedundertheProtocolonWaterand Health,particularlytheTaskForceonSurveillance. 8.1.WaterrelateddiseasesurveillanceinArmenia InArmenia,waterrelateddiseasesurveillanceisconductedbytheStateHygieneandAnti epidemiologicalInspectorateoftheMinistryofHealth.Waterrelateddiseasesurveillance systemsincludedrinkingwaterqualitysurveillanceandepidemiologicalsurveillancesystemsto preventandassessoutbreaks.

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Drinkingwaterqualitysurveillanceisconductedbysettingsanitaryepidemicsafetystandards, developingsanitaryandepidemiologicalrulesandnorms,aswellashygienestandards,and conductingcontrolswithregardtotheirrequirements.Sanitaryrulesandhygienenormsdefine environmentalsafetystandardsandhazardcriteriaforthepopulation,aswellasrequirements relatingtohazardconditionsforhumanactivity.Sanitaryrulesandhygienenormsdefine environmentalsafetystandardsandfavourablecriteriaforthepopulationaswellas requirementsrelatedtofavourableconditionsforhumanactivity. RegularandsituationaldrinkingwaterqualitymonitoringisconductedbytheStateHygieneand AntiepidemiologicalInspectorate.Monitoringofdrinkingwaterqualityisensuredbythe organizationoperatingthewatersupplysystem. Problemsincludelackofsufficientenvironmentalhealthregulations,monitoringrequirements andoutdatedwaterqualitycontrollaboratorymethodologies.Therequirementsofexisting sanitaryhygienicrulesarenotfullyenforced,especiallyrequirementsfordrinkingwatersource delineation,inventoryofthesignificantpotentialsourcesofwatercontaminationand developingprogrammesforpreventionofsourcewatercontamination.Rulerequirementsfor choosingalistofchemicalcontaminantsformonitoringaswellasextendedchemicalanalysis ofsourcewateraccordingtoitscontaminantsusceptibilityassessmentarenotconductedin anappropriatemannerbecausetherearenoreliabledataonsourcesofcontaminant vulnerability. Armeniaisdealingwithissuesofsecondarycontaminationofwaterbecauseofwornoutwater intakestructures,treatmentplantsanddistributionsystemnetworks,aswellasintermittent watersupplyandinsufficientleakdetectionmechanisms. Problemsconnectedwithdrinkingwaterrelateddiseasesurveillanceinclude: (a)lackofsufficientwaterqualitycontrollaboratorymethodologies; (b)lackofhydrogeologicalinventoryofthepotentialsourcesofchemical contaminationofdrinkingwatersources; (c)lackofdataonthevulnerabilityofsourcesandextendedanalysisofwater resourcesbasedonthevulnerabilityassessment; (d)lackofreliableinformationoncontaminationbyradionucleides, cryptosporidiumandLegionellaortheirimpactonthehealthofthepopulation. Inaddition,anumberofmeasuresneedtobetakentostrengthenandenhancetheprofessional skillsofthosedealingwithwater,throughtargetedtraining.Assuch: (a)intersectoraldataflowandinformationexchangeneedstobestrengthenedand facilitated; (b)surveillancesystemsneedtobecomemoreholisticintheirefforttopreventand assesswaterrelatedoutbreaks,includingdatacollection,exchangeand epidemiologicalinvestigation;andmanagementneedstoincludeevaluationof retrospectivedata,aswellasthecurrentstatus; (c)targetedsurveillancesystemsforwaterrelateddiseasesneedtobeimproved.

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8.2.TheSlovakexperienceofintersectoralcollaborationinwaterprotectionand management WaterprotectionandmanagementinSlovakiaistheresponsibilityoftheMinistryofthe Environment,mainlyincooperationwiththeMinistryofHealthandtheMinistryofAgriculture, andwithfinancialcontributionfromtheMinistryofFinance. TheWaterAct(No.364)of13May2004isthekeylegislationthatprotectswaterresourcesin Slovakia.EUlegislationinthisareaiscompletelytransposedintothisAct. TheMinistryoftheEnvironmentisthecentralbodythatmanagesStatewateradministrationin accordancewiththeaforementionedlegislation.Itisresponsibleforthetranspositionand implementationofEUdirectivesrelatedtowater,withtheexceptionofthedrinkingwaterand bathingwaterdirectives,whichremaintheresponsibilityoftheMinistryofHealth.On6 December2001theSlovakGovernmentadoptedResolutionNo.1138ontheintegrated approximationstrategyofSlovakiafortheenvironmentchapter,whichdefinedintersectoral cooperation. TheMinistryofAgriculturehasdevelopedacodexofgoodagriculturalpractice,ensuringthe protectionofwateragainstnitratesthroughtheimplementationofCouncilDirective 91/676/EECconcerningtheprotectionofwateragainstpollutioncausedbynitratesfrom agriculturalsources(theNitratesDirective),andisresponsibleforitsimplementation.The MinistryoftheEnvironmentdesignatesthesensitiveandvulnerableareas. ImplementationofDirective2006/7/ECoftheEuropeanParliamentandoftheCouncilof15 February2006concerningthemanagementofbathingwaterqualityandrepealingDirective 76/160/EECwasensuredincooperationwiththeMinistryofHealthandtheMinistryofthe Environment.TheMinistryofHealthandtheMinistryoftheEnvironmentjointlydesignate bathingwaters. TheMinistryoftheEnvironmentanditslocalrepresentativescooperatewithlocalauthoritiesin issuingpermitswithindividualproducerswiththeaimtosetupdischargelimitsinthe implementationofCouncilDirective76/464/EECof4May1976onpollutioncausedbycertain dangeroussubstancesdischargedintotheaquaticenvironmentoftheCommunity.Inorderto eliminateindustrialpollutionoftheenvironment,theMinistryoftheEnvironmentcooperates withotherbodies,suchastheAssociationofIndustrialEcology,anNGO. CouncilDirective91/271/EECof21May1991concerningurbanwastewatertreatmentisbeing implementedbywaterservicesandlocalgovernments,butitsimplementationiscarriedoutin accordancewiththeplanforthedevelopmentofpublicwatersupplysystemsandpublic seweragesystemsintheterritoryofSlovakia.Thisplanwastakenintoconsiderationbythe Government.Duringitspreparation,representativesoftheAssociationofTownsand CommunitiesofSlovakia(ZMOS)werepresent,representingmorethan96%ofall municipalities. TheMinistryoftheEnvironmenthascarriedoutfloodriskmanagementplans,whichare prepared,implementedandupdatedincooperationwithZMOSrepresentatives. PreventionoffloodsandmanagementoffloodimpactsistheresponsibilityoftheCentralFlood ProtectionCommission.TheMinisteroftheEnvironmentistheChairoftheCommission,with

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theMinisterofInternalAffairsashisdeputy.AllotherministersaremembersoftheCommission andcooperateinharmonywithinthemandatesoftheirrespectivejurisdictions.TheMinistryof theEnvironmentinvitesstakeholdersfordiscussionandpreparationofkeydocuments,suchas thePlanfortheDevelopmentofPublicWaterSupplySystemsandPublicSewerageSystemsfor theTerritoryoftheSlovakRepublic,aswellasfloodriskmanagementplans.Inadditionto representativesoftownsandcommunities,NGOsarealsoinvited.DocumentsfromtheMinistry oftheEnvironmentandMinistryofHealthareavailabletothepublicontheirwebsitesandare openforcomments. Informationregardingenvironmentalissuesispresentedtothepublicthroughtheculturalfilm festival,theInternationalFestivalofSustainableDevelopmentFilms(EKOTOPFILM).Themain organizerofthefestivalistheagencyEKOTOPFILM,incooperationwithotherpartners professionalguarantors13ministersoftheSlovakGovernment,thecapitalcityofBratislava andvariousNGOs. TheMinistryofHealthandtheMinistryoftheEnvironmentworktogethertoimplementthe ProtocolonWaterandHealth.In2003bothministriespreparedanationalreportonthestatus ofimplementationoftheProtocol,includingtargetsandtargetdates,whichwasapprovedby theGovernmentandupdatedin2005.Thisdocumentwasreplacedin2006bythenational targets. 8.3.Norway:exampleofcomplementarityofwaterqualitymonitoringanddisease outbreakdetection Thecurrentregulatorysystem,basedonEUCouncilDirective98/83/EConthequalityofwater intendedforhumanconsumptionimposesasamplingfrequencywherebyforeachlitre analysed,600millionlitresaredeliveredtotheconsumer.Comparingthistoaroadbetween RomeandOslo,thisequatestotheyearlyexaminationof5mmofa2008kmroad.Itis thereforenotsurprisingthatnooutbreakshavebeendiscoveredinNorwaythroughwater analysesalone,althoughtheyremainapowerfultooltoestablishretrospectivelytheconnection betweenanoutbreakandthedrinkingwatersupplyquality. NorwayhasprogressivelydevelopedaregulatoryapproachsimilartotheconceptofaWSP. (a)HygienicSafety1951:sourceprotection,watertreatmentaccordingtoneed (earlyexampleofdoublesafetymeasures). (b)HygienicSafety1995:minimumoftwohygienicbarriersagainstallkindsof contaminants. (c)Regulation2001:minimumoftwohygienicbarriersagainstallkindsof contaminants(multiplebarriersystem). AlthoughWSPsarethecurrentbasisofnegativehealthimpactprevention,oneshouldremain awarethatgapsinthesystemmaystillcausefailures. Emphasisshouldbeplacedonunderstandingthecapacityaswellastheweaknessesof surveillancesystems,basedonindicatororganisms.Traditionalindicators,suchasE.coli, coliformsandintestinalenterococcimaybecommonlyseenasgoodindicatorsforpriority pathogens,suchasVibriocholerae,ShigelladysenteriaeorSalmonellatyphi,becausetheyhave similarsurvivalcharacteristicsinwaterandexhibitcomparablesensitivitytodisinfection.

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However,somepathogensmaysurvivedisinfectionbetterthantheclassicindicatororganisms. Examplesofsuchhardierpathogensareviruses(norovirus),protozoa(Giardiaintestinalis, Cryptosporidiumparvum,Entamoebasp.)andevencertain(sporeforming)bacteria. 8.4.Croatia TheActontheProtectionofthePopulationfromInfectiousDisease(OfficialJournalofthe RepublicofCroatiaNN60/92)defines75diseasesasnotifiable,andthelistisupdatedyearlyby theMinistryofHealth.Twodevolvingregulationsareimportantwithregardtowaterrelated diseasesurveillance:theInfectiousDiseaseNotificationMethodRegulation(NN23/94)andthe DrinkingwaterSafetyRegulation(NN182/04).Uponanysuspicionofinfectiousdisease,the physicianshouldimmediatelynotifythelocalhygieneandepidemiologicalofficesofthe NationalInstituteofPublicHealth.TheEpidemiologicalServiceoftheInstitutereportsregularly totheMinistryofHealthontrendsininfectiousdiseases,andonanyanygroupingofdisease overashortperiodoftime.Whencasesofaninfectiousdiseaseexhibitagroupingthatgoes beyondthelocallevel,aninterventionbytheInstitutebecomesmandatory.Thisisalso obligatoryinthecaseoflargeepidemics,epidemicsofunknowncausesandtheoutbreakof diseasesthecontrolofwhichisverycomplicated.Since2004,laboratorytestinghasbeen conductedonsamplesforwhichnorovirusinfectionissuspected. Allinstitutionsarerequiredtoimmediatelyinformtheirownepidemiologicalserviceswhen wateranalysisshowsthatanymicrobiologicalorchemicalfactorsposeahealthhazard.Atthe internationallevel,CroatiainformsWHOoftheincidenceandnumberofcasesofinfectious diseases. 8.5.Hungary InHungary,communicablediseasesarenotifiable,includingalldiseasesidentifiedasimportant undertheProtocolonWaterandHealth.CasedefinitionsestablishedbyWHOwereadoptedin 1998. Therearethreeadministrativelevelsinreporting:national,countyandmunicipal.Initial notificationiscarriedoutbyhealthcareproviderstothemunicipalinstitutions.TheHungarian reportingsystembenefitsfromfourtypesofinformationsource,asdetailedhere. (a)Physiciansreportdataoncasereportforms. (b)Microbiologicallaboratoriesparticipateinlaboratorybasedsurveillance systems. (c)Sporadiccasesofcertaindiseasesareinvestigatedandcaseinvestigationforms areroutinelyprocessed.Incaseofimportantdiseaseoutbreaks,socalledearly reportingformsaretobecompletedwithin24hours. (d)Epidemiologicalinformationonoutbreaksisavailable,aseachoutbreakmustbe investigated. SuspectedoutbreaksarereportedbyexpertsoftheNationalPublicHealthandMedicalOfficers Service,whichisresponsibleforinvestigatingoutbreaks.Reportingfrequencythroughthe serviceisthreefold: (a)immediatereportwhenthereissuspicionofanoutbreak;

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(b)weeklyreportintermediateresultsoftheoutbreakinvestigation; (c)summaryreportassoonasalltheepidemiologicalandmicrobiological informationhasbeenobtained. Accordingtothestrengthofevidenceforassociationbetweenexposureandillness,outbreaks areclassifiedaspresumptive(humancasesthatarenotlaboratoryconfirmed),confirmedbased onepidemiologicaldata(descriptiveepidemiologicalstudysuggestsassociation)andlaboratory confirmed(etiologicalagentdetectedandidentified). From1955to2004,therewere237waterbornediseaseoutbreaksinHungary. 8.6.Germany TheGermansurveillancesystemisbasedontheInfectionProtectionAct(2001),whichgoverns thecompetencebetweentheFederalGovernment(Bund)andthestates(Lnder)withregardto thesurveillanceofinfectiousdiseases.The16statesconductthesurveillanceandare responsibleforthereporting.ThecasedefinitionsofnotifiablediseasesarebasedonEUcase definitions,andmostlaboratoryresultsonacutecasesarenotifiable.Laboratoriesand physiciansindependentlyreportnotifiablecasestothelocalhealthdepartmentswithin24hours aftercaseconfirmation.Forsomediseaseswithahighburden,suchascholera,thelocalhealth departmentisnotifiedevenifacaseissuspectedbutnotyetconfirmed. Thelocalhealthdepartmentsreporttothestatedepartment,whichthenreportswithinone weektothenationalsurveillanceinstitution,theRobertKochInstitute.Bylawitshouldnottake morethanfourweeksfromcaseconfirmationtopublicationintheweeklybulletinoftheRobert KochInstitute;inpractice,theprocessisusuallycompletedwithinthreeweeks. Theidentificationofthesourceofinfection,andthustheidentificationofoutbreaks,iscarried outatthelocallevel.Uponrequest,theRobertKochInstitutewillprovidesupportforthelocal healthdepartmentsinthedetectionofthesourceofinfection.Informationrelatingtothe outcomeoftheseinvestigationsmaybereportedtothefederalGovernment,butthisisnot obligatory. TheGermansystemisveryeffectiveinpickingupevensmalloutbreaks.Therefore,70%ofall EuropeaninfectiousdiseaseoutbreaksareregisteredasoriginatinginGermany.Thisresult reflectsthequalityofthesurveillancesystemmorethanthecomparativehealthrisksinthe participatingcountries.Inordertoassurethehighqualityofthesurveillancesystem,training coursesareprovidedeveryyearforlocalandstatehealthdepartmentprofessionalson epidemiologicalmethodology,inparticularwithregardtooutbreakinvestigations. 8.7.Finland:surveillanceofwaterborneoutbreaks InFinland,foodborneandwaterborneoutbreakshavebeenmonitoredsince1980.The voluntaryreportingsystemfoundoccasionaloutbreakseveryyearbutsmalloutbreakswith comparativelyfewcasesundoubtedlyremainedunknown.Asignificantchangetookplacein 1997,whenanewnotificationsystemforwaterborneoutbreakswaslaunched.Accordingtothis system,municipalhealthprotectionauthoritiesthatareresponsibleforfrequentmonitoringof thequalityofdrinkingwaterareobligedtonotifyallsuspectedwaterborneoutbreakstothe NationalInstituteforHealthandWelfare(THL).Thepurposeofthepreliminarynotificationisto

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obtaininformationimmediatelyrelatingtotheextentofanoutbreak,thesymptomsofpatients, thesuspectedcausativeagentofanoutbreak,themanagementandremedialactionstakenand thecontactdetailsofauthoritiesengagedwiththeoutbreak.TheTHLmaintainsanationaltask group,whichhelpslocalauthoritieswithtechnical,analyticalandepidemiologicalproblems associatedwithwaterborneoutbreaks. Thedetectionofawaterborneoutbreakisnotaneasytask.Thereisnormallyacommon disbeliefinanoutbreak.Usually,asuddenincreaseofillnesscasesistheonlysymptomofan outbreak.Themonitoringresultsofdrinkingwateranalyses,bothmicrobiologicalandchemical, usuallycomplywiththequalityrequirements,thushamperingthedetectionofanoutbreak.A fastactingandfluentcooperationandcommunicationsystembetweenbodiesworkingwiththe healthandwatersectoristhereforethemostimportantfactortoprevent,restrictandsolvean outbreak. Afterlaunchingthecompulsorynotificationsystemforwaterborneoutbreaks,eventhesmallest outbreaksassociatedwiththeuseofprivatewellsarerevealed,whichcanbeseeninthehigher numberofwaterborneoutbreaksafter1997(seeFig.1.).Since1999therehavebeen59 outbreaks,withatotalof27000illnesscases.Outbreakshavetypicallybeenassociatedwiththe useofgroundwaterthathasnotbeendisinfected,insmallcommunitieswithfewerthan500 consumers.Norovirusesandcampylobacteriahavebeenthemostcommoncausativeagents behindtheoutbreaks.

Waterborne outbreaks in Finland 1980-2006

Number of waterborne outbreaks
12 10 8 6 4 2 0 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 Compulsory notification system for waterborne outbreaks

Year

Fig.1.NumberofwaterborneoutbreaksinFinland19802006 Source:FinnishFoodSafetyAuthorityEvira,2007

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8.7.1Advantagesofthecompulsorynotificationsystem

Immediatenotificationofanoutbreakacceleratesthecooperationbetweenauthorities,water companies,laboratoriesandtheTHL,andenablesthedesignofimmediatemanagementand remedialactiontocontrolandrestricttheoutbreakandtopreventharmfulhealtheffects.The notificationsystemhasdecreasedthedetectionthresholdofanoutbreakandincreasedthe awarenessofpossiblemicrobiologicalproblemsassociatedwiththequalityofdrinkingwater. Figuresonwaterborneoutbreaksaremorerealistictodaythanbeforetheintroductionofthe system,althoughthenumberofillnesscasesmaystillbeunderestimated. Today,authoritiesandwatercompaniesareperhapsmorecapableofreactingtopotential problemsandmalfunctionsrelatedtowaterservices.Knowledgeaboutwaterborneoutbreaks associatedwiththeuseofgroundwaterhas,forexample,increasedtheuseofdisinfection methodssuchasultravioletradiationingroundwatersupplies.Contingencyplans,risk assessmentandriskmanagementhavebeenorarebeingdevelopedbywatercompanies. Informationandcommunicationsystemsrelatedtowaterborneoutbreakshasbeenimproved throughnewlegislationondrinkingwater.Legislationalsorequiressupplementaryeducation andskillexaminationsforpersonnelworkinginwatertreatmentplants.Atfiveyearintervals, personnelshouldparticipateinandpassanexaminationinwaterserviceandhygiene. Guidebooksandreportshavebeenpublishedon,forexample,operationandmaintenanceof waterworks,securityofwatersuppliesandprovisionofinformationincasesofsevereincidents. Researchprogrammeshavebeendevelopedtopromoteresearchactivitiesrelatedtowater servicesandsanitation.

Policy guidance on water-related disease surveillance page 21

CONTRIBUTORS
TheWHORegionalOfficeforEuropeisgratefultotheUnitedNationsEconomicCommissionfor Europe(UNECE)forprovidingtheoriginalfundingfortheworkthatledtothispublication RogerAertgeerts,WHORegionalOfficeforEurope,(CoSecretaryoftheProtocol) EnzoFunari,ChairoftheTaskForceonSurveillance,Italy NanaGabriadze,DeputyHeadofPublicHealthDepartment,NationalCentreforDiseasecontrol andPublicHealthofGeorgia PaulHunter,SchoolofHealthMedicine,HealthPolicyandPractice,UniversityofEastAnglia, UnitedKingdom FrantisekKozisek,Director,NationalInstituteofPublicHealth,CzechRepublic ArbenLuzati,Head,EnvironmentalHealthDepartment,InstituteofPublicHealth,Albania AidaPetikyan,Head,EnvironmentalandCommunalHygieneDepartment,StateHygienicAnti epidemiologicalInspection,MinistryofHealth,Armenia AndreaRechenburg,Executivemanager,UniversityClinicBonn,InstituteofHygieneandPublic Health,Germany

Policy guidance on water-related disease surveillance page 22

DOCUMENTSUSEDFORTHEPREPARATIONOFTHEGUIDANCE
EikebrokkB(2005),ReporttotheBergencitycouncilfromtheexternalexpertcommitteefor evaluationoftheGiardiaoutbreakinBergenautumn2004,Helsinki. FinnishFoodSafetyAuthority(Evira)(2007).FoodborneandwaterborneoutbreaksinFinland 2006.Helsinki,FinnishFoodSafetyAuthorityEvira(21/2007). WHO(1959).Watersupplyforruralareasandsmallcommunities.Geneva,WorldHealth Organization,(MonographSeriesNo.42). WHO(1989).Healthguidelinesfortheuseofwastewaterinagricultureandaquaculture. Geneva,WorldHealthOrganization,(TechnicalReportSeriesNo.778). WHO(2004).Guidelinesfordrinkingwaterquality,incorporatingfirstandsecondaddendato thethirdedition,Volume1Recommendations.Geneva,WorldHealthOrganization. WHO(2005)Watersafetyplans:managingdrinkingwaterqualityfromcatchmenttoconsumer. Geneva,WorldHealthOrganization. WHO(2007).Combatingwaterbornediseaseatthehouseholdlevel,Geneva,WorldHealth Organization. WHO(2008).Waterqualityinterventionstopreventdiarrhoea:costandcosteffectiveness. Geneva,WorldHealthOrganization. WHORegionalOfficeforEurope(2006).Finalreport:consultationonwaterbornediseases surveillance,910May2006,Budapest,Hungary.Copenhagen,WHORegionalOfficeforEurope. UNECE,WHORegionalOfficeforEurope(2007a).ProtocolonWaterandHealthtothe1992 ConventionontheProtectionandUseofTransboundaryWatercoursesandInternationalLakes. GenevaandCopenhagen,UnitedNationsEconomicCommissionforEuropeandWHORegional OfficeforEurope. UNECE,WHORegionalOfficeforEurope(2007b).Surveillanceofwaterrelateddiseases.Geneva andCopenhagen,UnitedNationsEconomicCommissionforEurope,WHORegionalOfficefor Europe. UNECE,WHORegionalOfficeforEurope(2007c).Reportofthemeetingofthepartiestothe ProtocolonWaterandHealthtotheConventionontheProtectionandUseofTransboundary WatercoursesandInternationalLakesonitsfirstmeeting(Geneva,1719January).Genevaand Copenhagen,UnitedNationsEconomicCommissionforEurope,WHORegionalOfficefor Europe.

The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan
ISBN 978 92 890 0236 3

POLICY GUIDANCE ON WATER-RELATED DISEASE SURVEILLANCE

World Health Organization Regional Office for Europe

Scherfigsvej 8, DK-2100 Copenhagen , Denmark Tel.: +45 39 17 17 17. Fax: +45 39 17 18 18. E-mail: contact@euro.who.int Web site: www.euro.who.int