title: A large waterborne outbreak of campylobacteriosis in Norway: the need to focus on distribution system safety.
abstract: BACKGROUND
  On 7 May 2007 the medical officer in Røros (population 5600) reported 15 patients with gastroenteritis. Three days later he estimated hundreds being ill. Untreated tap water from a groundwater source was suspected as the vehicle and chlorination was started 11 May. Campylobacter was isolated from patients' stool samples. We conducted an investigation to identify the source and describe the extent of the outbreak.
  
  
  METHODS
  We undertook a retrospective cohort study among a random sample of customers of Røros and neighbouring Holtålen waterworks. Holtålen, which has a different water source, was used as a control city. We conducted telephone interviews to gather data on illness from all household members. One randomly selected household member was asked about detailed exposure history. The regional hospital laboratory tested patients' stools for enteropathogens. Campylobacter isolates were typed by AFLP for genetic similarity at the Norwegian Institute of Public Health. Local authorities conducted the environmental investigation.
  
  
  RESULTS
  We identified 105 cases among 340 individuals from Røros and Holtålen (Attack Rate = 31%). Tap water consumption was the only exposure associated with illness. Among randomly selected household members from Røros, a dose-response relationship was observed in daily consumed glasses of tap water (chi2 for trend = 8.1, p = 0.004). Campylobacter with identical AFLP was isolated from 25 out of 26 submitted stool samples. No pathogens were detected in water samples. We identified several events that might have caused pressure fall and influx of contaminated water into the water distribution system. On two occasions, pressure fall was noticed and parts of the distribution system were outdated.
  
  
  CONCLUSIONS
  The investigation confirmed a waterborne outbreak of campylobacteriosis in Røros. Although no single event was identified as the cause of contamination, this outbreak illustrates the vulnerability of water distribution systems. Good quality source water alone is not enough to ensure water safety. For a better risk management, more focus should be put on the distribution system security. Waterworks personnel should monitor the pressure regularly; reduce the leakage by upgrading the distribution network and use chlorination when conducting maintenance work.
authors.affiliation: Department of Infectious Disease Epidemiology, Norwegian Institute of Public Health, PO Box 4404 Nydalen, N-0403 Oslo, Norway. irena.jakopanec@fhi.no
authors.forename: Irena
authors.initials: I
authors.lastname: Jakopanec
authors.forename: Katrine
authors.initials: K
authors.lastname: Borgen
authors.forename: Line
authors.initials: L
authors.lastname: Vold
authors.forename: Helge
authors.initials: H
authors.lastname: Lund
authors.forename: Tore
authors.initials: T
authors.lastname: Forseth
authors.forename: Raisa
authors.initials: R
authors.lastname: Hannula
authors.forename: Karin
authors.initials: K
authors.lastname: Nygård
mesh_terms: D054458:Amplified Fragment Length Polymorphism Analysis; D002167:Campylobacter / Q000235:genetics / Q000302:isolation & purification*; D002169:Campylobacter Infections / Q000453:epidemiology*; D015331:Cohort Studies; D004196:Disease Outbreaks; D005243:Feces / Q000382:microbiology; D005618:Fresh Water / Q000382:microbiology; D005759:Gastroenteritis / Q000453:epidemiology* / Q000209:etiology; D006801:Humans; D015994:Incidence; D009664:Norway / Q000453:epidemiology; D012189:Retrospective Studies; D014871:Water Microbiology; D014881:Water Supply