title: Fault tree analysis of the causes of waterborne outbreaks.
abstract: Prevention and containment of outbreaks requires examination of the contribution and interrelation of outbreak causative events. An outbreak fault tree was developed and applied to 61 enteric outbreaks related to public drinking water supplies in the EU. A mean of 3.25 causative events per outbreak were identified; each event was assigned a score based on percentage contribution per outbreak. Source and treatment system causative events often occurred concurrently (in 34 outbreaks). Distribution system causative events occurred less frequently (19 outbreaks) but were often solitary events contributing heavily towards the outbreak (a mean % score of 87.42). Livestock and rainfall in the catchment with no/inadequate filtration of water sources contributed concurrently to 11 of 31 Cryptosporidium outbreaks. Of the 23 protozoan outbreaks experiencing at least one treatment causative event, 90% of these events were filtration deficiencies; by contrast, for bacterial, viral, gastroenteritis and mixed pathogen outbreaks, 75% of treatment events were disinfection deficiencies. Roughly equal numbers of groundwater and surface water outbreaks experienced at least one treatment causative event (18 and 17 outbreaks, respectively). Retrospective analysis of multiple outbreaks of enteric disease can be used to inform outbreak investigations, facilitate corrective measures, and further develop multi-barrier approaches.
authors: School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, NR4 7TJ, UK. h.risebro@uea.ac.uk
authors: Helen L
authors: HL
authors: Risebro
authors: Miguel F
authors: MF
authors: Doria
authors: Yvonne
authors: Y
authors: Andersson
authors: Gertjan
authors: G
authors: Medema
authors: Keith
authors: K
authors: Osborn
authors: Olivier
authors: O
authors: Schlosser
authors: Paul R
authors: PR
authors: Hunter
mesh_terms: D021821:Communicable Diseases, Emerging / Q000453:epidemiology / Q000209:etiology*; D003663:Decision Trees; D004196:Disease Outbreaks; D005062:European Union; D006801:Humans; D012308:Risk Management; D014871:Water Microbiology; D014881:Water Supply / Q000032:analysis*