Park et al.

- A waterborne outbreak of multiple diarrhoeagenic Escherichia coli infections

associated with drinking water at a school camp

Background: Park et al.’s paper investigates the waterborne gastroenteritis outbreak in a Korean
school camp, which occurred in 2015. Gastroenteritis, also known as infectious diarrhea and
gastro, is inflammation of the gastrointestinal tract; the stomach and intestine. The outbreak was
caused by the bacterium, diarrhoeagenic Escherichia coli (DEC). DEC can be divided into five
groups based on virulence properties: enterohaemorrhagic E. coli (EHEC), enteropathogenic E.
coli (EPEC), enterotoxigenic E. coli (ETEC), enteroaggregative E. coli (EAEC), and
enteroinvasive E. coli (EIEC). Depending on the group, symptoms can vary from mild diarrhoea,
vomiting, to severe haemorrhagic colitis. Usually, an outbreak is caused by a single strain,
however in this case, multiple DEC strains were found. DEC is spread through food or water
contaminated with human or animal feces and thus is transmitted via the oral route. There is no
current vaccine or treatment that can cure a DEC infection, relieve the symptoms or prevent
complications. Mostly, treatment is limited to rest and fluids that help prevent dehydration and
fatigue.

The WHO Global Burden of Foodborne Diseases report estimates that more than 300 million
illnesses and nearly 200,000 deaths are caused by DEC globally each year. Cases of infection vary
by region. In Korea (the focus of the study), between 2012-2015, 25.6% of cases of acute
bacterial diarrhea were due to pathogenic E.coli. In fact, EHEC infection has been recognized as a
nationally notifiable disease in Korea and was linked to 12 foodborne and waterborne outbreaks
from 2012 to 2015.

Data: The researchers collected data on three schools that reported students experiencing
gastrointestinal symptoms after attending the same camp located in Jeollabuk-do from June 3 to June
5. Firstly, they conducted an interview on 475 people who attended the camp including camp staff,
students, and teachers “using a standard questionnaire that addressed clinical symptoms, food
consumption, and environmental exposures while attending the camp, and the time of symptom
onset.” Secondly, three local public health laboratories were recruited to collect and test clinical
specimens from rectal swabs of suspected cases. A total of 235 rectal swabs were collected. The tests
confirmed the presence of DEC strains using an 8-plex PCR assay. Thirdly, they conducted an
environmental investigation by inspecting camp facilities, interviewing the catering staff and
reviewing food safety records. Also, environmental specimens were collected from the food items
served and cooking utensils. Samples were also taken from water, including the drinking water, a
valley near the camp, and washbasins. These were tested for the presence of any bacteria or virus,
and the residual free chlorine concentrations in the drinking water samples were also measured.

Findings: The outbreak had an attack rate of 30.9%, affecting 188 out of 609 people. Common
symptoms included diarrhea, abdominal pain, nausea, chills, fever, and vomiting. The completed
questionnaires indicated that some food items, but especially drinking water served at the camp had
likely spread the infection. From the 235 rectal swabs collected, 82 (34.9%) samples were positive
for DEC, with type EPEC being the most common. From the environmental samples, 14 of type
EHEC strains were found in the drinking water from the cafeteria and 4 type EPEC strains were
found from water and a washbasin. Also, these strains showed the same PFGE banding patterns, thus
supporting the hypothesis that the main cause of the outbreak was the drinking water. The water
system in the camp used ground water drawn from a private underground reservoir for cooking and
drinking. There were problems with the system, including the use of inappropriate filters in the water
purifier; defect in the pipeline between the reservoir and the chlorination device; as well as not
maintaining residual free chlorine levels at the recommended level. These issues had increased the
chances of contamination in the water distribution system, which then caused the spread of the
disease. However, the potential sources of the ground-water contamination were not found. To
control the outbreak, they implemented a disinfection process of the sewage system and a filtration
system that removed dissolved particles including parasites, bacteria, viruses etc. The camp also
conducted a purification process for the drinking water to remove contaminants. Moreover, the
cafeteria filter was replaced with a reverse osmosis membrane which would remove viruses and
bacteria during the purification process, and after all of this, chlorination was done again.

Limitation: A limitation of the study is that the results are contingent upon the data collected
from the interview questionnaire being accurate. The questionnaire conducted on all the attendees
of the camp was more qualitative based, where they were asked about symptoms, food
consumption, environmental exposures etc. This means there could be a chance of participants not
responding truthfully or accurately resulting in unreliable and skewed data. Also, the
questionnaire was not conducted on all attendees so there is a chance of unreported cases, thus the
severity of the outbreak may be underestimated.

Implications: Waterborne outbreaks associated with private water systems should not be
underestimated. Even in a private setting, diseases spread quickly and uncontrollably. Public water
quality is always given higher importance. Groundwater is usually thought of as relatively safe to use
but this study shows how it can also trigger a disease outbreak. Even though most drinking water in
private settings meet the required standards, because there are no regular checks, the final water used
may still get contaminated over just a few days or even overnight due to faulty distribution systems.
Indeed, as the researchers recommend, where groundwater is used, there must be regular checks and
management of drinking water quality with respect to waterborne diseases, to prevent any outbreak.
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multiple diarrhoeagenic Escherichia coli infections associated with drinking water at a
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WHO estimates of the global burden of foodborne diseases. 2015