title: A waterborne outbreak in Missouri of Escherichia coli O157:H7 associated with bloody diarrhea and death.
abstract: OBJECTIVE
  To describe and determine the source of a large outbreak of Escherichia coli O157:H7 (ECO157) infections in Missouri.
  
  
  METHODS
  A case-control study and a household survey.
  
  
  METHODS
  A small city in a rural Missouri township that had an unchlorinated water supply.
  
  
  METHODS
  Case patients were residents of or visitors to Burdine Township with bloody diarrhea or diarrhea and abdominal cramps occurring between 15 December 1989 and 20 January 1990.
  
  
  METHODS
  Escherichia coli O157 was isolated from 21 stool specimens. All isolates were resistant to sulfisoxazole, tetracycline, and streptomycin; produced Shiga-like toxins I and II; and had one 60-megadalton plasmid.
  
  
  RESULTS
  Among the 243 case patients, 86 had bloody stools, 32 were hospitalized, 4 died, and 2 had the hemolytic uremic syndrome. In the case-control study, no food was associated with illness, but ill persons had drunk more municipal water than had controls (P = 0.04). The survey showed that, during the peak of the outbreak, bloody diarrhea was 18.2 times more likely to occur in persons living inside the city and using municipal water than in persons living outside the city and using private well water (P = 0.001). Shortly before the peak of the outbreak, 45 water meters were replaced, and two water mains ruptured. The number of new cases declined rapidly after residents were ordered to boil water and after chlorination of the water supply.
  
  
  CONCLUSIONS
  This was the largest outbreak of ECO157 infections, the first due to a multiply resistant organism, and the first shown to be transmitted by water. System-wide chlorination as well as hyperchlorination during repairs might have prevented this outbreak. Both bloody and nonbloody diarrhea may be common manifestations of this infection, which is probably underdiagnosed because of the failure of routine stool cultures to identify the organism. Cities with deteriorating water systems using untreated water risk widespread illness from contaminated drinking water.
authors.affiliation: Enteric Diseases Branch, Centers for Disease Control, Atlanta, GA 30333.
authors.forename: D L
authors.initials: DL
authors.lastname: Swerdlow
authors.forename: B A
authors.initials: BA
authors.lastname: Woodruff
authors.forename: R C
authors.initials: RC
authors.lastname: Brady
authors.forename: P M
authors.initials: PM
authors.lastname: Griffin
authors.forename: S
authors.initials: S
authors.lastname: Tippen
authors.forename: H D
authors.initials: HD
authors.lastname: Donnell
authors.forename: E
authors.initials: E
authors.lastname: Geldreich
authors.forename: B J
authors.initials: BJ
authors.lastname: Payne
authors.forename: A
authors.initials: A
authors.lastname: Meyer
authors.forename: J G
authors.initials: JG
authors.lastname: Wells
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D003967:Diarrhea / Q000453:epidemiology / Q000382:microbiology*; D004196:Disease Outbreaks; D004352:Drug Resistance, Microbial; D004926:Escherichia coli / Q000302:isolation & purification; D004927:Escherichia coli Infections / Q000453:epidemiology* / Q000209:etiology / Q000401:mortality; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology / Q000382:microbiology*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D008923:Missouri / Q000453:epidemiology; D012044:Regression Analysis; D012423:Rural Health; D014871:Water Microbiology