WATER-BORNE MASSIVE GASTROENTERITIS OUTBREAK IN MÁLAGA

Authors: Gómez Pozo, Basilio*. García España Francisco†. González Pérez, Yolanda*

INTRODUCTION
Between the 31st and 34th epidemiology weeks in 1995, a great number of people
living in a broad area (522,103 inhabitants) of Málaga, were affected of gastroenteritis.
During the first days of August, a crack in the tap-water network nearby the affected
area occurred, which led to the service break during the time needed for it to be
repaired.
All the information above, given by the own sufferers, who warned the
Epidemiology Service and the one from the Mandatory Notifiable Diseases -MND-,
which showed the increasing number of patients, suggested a water-related transmission
by the tap-water network, as the first hypothesis concerning the origin of this outbreak;
there must not be forgotten other possible areas: hygienic deficiencies in the tanks
(which distributed the water among each building or group of buildings), or the
existence of small markets that could be distributing contaminated products.

AREA DESCRIPTION
The epidemy ended up being limited to eight neibourhoods of Málaga among
five Health Basic Areas (HBA) attended in two surgeries and one health center. All
those five HBA comprised a population of 90,755 inhabitants (some less than a third
part of the District’s population).
All this area is supplied from a chlorinating tank with pipelines embracing all the
mentioned neighbourhoods in a big circle.

METHODS

CONFIRMATION OF THE OUTBREAK

In MND code “Other diarrhoeal processes” during the 32nd epidemiology week
(the one with a higher incidence of this illness), the following were notified:

204 cases in Gamarra’s surgery.

582 cases in Miraflores’s surgery.
221 cases in Palma-Palmilla’s health center.

These 1,007 declared cases mean an incidence rate (for the population belonging
to these assistance centers) of 1,109 x 105 inhabitants.

*
Málaga Health District (E-mail: dsmalaga@eia-spain.com).
†
Province Health Office.
 Figure 1: Represents the epidemic curve as to the item: “ Other diarrhoeal Processes”.

Figure 2: Shows that same curve limited to the interviewed subjects.

The incidence rates (using the average rates for the years 1992, 1993 and 1994,
as the expected value) are:

2.72 for the HBA of Gamarra (including Nueva Málaga).

8.43 for the HBA of Miraflores (including Rosaleda).
5.39 for the HBA of Palma-Palmilla.

QUESTIONNAIRE
A questionnaire was designed to gather information concerning basic clinical
and epidemiological variables.
Family doctors from the surgeries in Gamarra and Miraflores, complied data
from those patients that came to their centers, and epidemiologists from the Province
Health Office and District completed it by actively searching for cases and their controls
by home visits and telephone calls.

CASE AND CONTROL DEFINITION

It was considered a case every fever patient accomplishing the following
conditions:
Existence of, at least, abdominal pain and diarrhoea (the most frequent and serious
symptoms).
Date of initial symptoms from 31-07-95 to 22-08-95 (to include both early and
secondary symptoms).
 Address in some of the neighbourhoods mentioned above (in agreement with the
water network probably involved.
The controls were defined by:
Lack of symptoms.
Same restrictions as for address (in all cases this means relative controls).
If the residence was different from that of the cases, the presence (possibility of an
exposure) was needed during the outbreak course.

ANALYSIS

PERSONAL CHARACTERISTICS
Patients were classified in 115 cases and 114 controls (41 observations were not
used for analysis, for not accomplishing the defining criteria of case or control). The
cases represent more than 10% of all declared patients.

PUBLIC HEALTH ALERT Nº 42/1995 (MALAGA)

PERSONAL CHARACTERISTICS

56 57
CASES (113)

57 57
CONTROLS (114)

70 60 50 40 30 20 10 0 10 20 30 40 50 60 70
MALE FEMALE

N = 229 (sex, was not recorded in two people)

Source: Interview
Figure 3

PUBLIC HEALTH ALERT Nº 42/1995 (MALAGA)

PERSONAL CHARACTERISTICS

AGE GROUP
0-14 34 20
15-29 26 31
30-44 20 33
45-59 15 17
60-74 14 8
75-89 3 3
40 30 20 10 0 10 20 30 40
NUMBER OF CASES NUMBER OF CONTROLS

N = 229 (age was not recorded in five people)

Source: Interview
Figure 4

Figures 3 and 4 describe the distribution by sex and age groups for cases and controls:
As to the frequency distribution of signs and symptoms, the picture is like in the following figure 5:

PUBLIC HEALTH ALERT Nº 42/1995 (MALAGA)

CLINICAL PICTURE
SIGNS AND SYMPTOMS
DIARRHOEA 92

ABDOMINAL PAIN 83

FEVER 34

NAUSEA 32

VOMITING 25

0 20 40 60 80 100 120
PERCENTAGE OF PATIENTS

155 patients (115 were considered as cases)

Source: Interview
Figure 5
Table 1 Shows the crude analysis of the relationship found between this illness and
different considered dosages of exposure to the tap-water from that network.

DOSAGE ODDS RATIO 95% EXACT CONFIDENCE LIMITS

WASHING * 2.04 0.77-5.84
ICE CUBES† 3.22 1.49-7.07
DRINKING‡ 3.17 1.60-6.44
Table 1

Table 2 A test for the analysis of trend (Mantel), related to the exposure dosages, gives
the following values.

EXPOSURE DOSAGE EXPOSURE ODDS ODDS RATIO

NOT EXPOSED 8/25 1*
WASHING 34/52 2.03
ICE CUBES 28/16 5.47
DRINKING 40/17 7.34
Table 2
*
Reference group / x 2 Trend = 23.932 p<0.00000

In table 3 appears the test of trends for two types of different severity cases: Existence
of, at least, diarrhoea -DCASE-. Existence of, at least, diarrhoea and abdominal pain -
DPCASE-, for the exposure to tap-water of the network at maximal dosages:

SEVERITY DISEASE ODDS ODDS RATIO

HEALTHY PEOPLE 17/97 1*
DCASE 44/95 2.64
DPCASE 40/72 3.17
Table 3
2
*Reference group / x Trend = 12.232 p<0.00047

Table 4 Finally, a non-conditional logistic regression model was adjusted §: it was considered
as variable of interest the exposure to the tap-water of that network at different dosages
(defined as dummy variables: WASHING, ICE, DRINKING).

Covariables: AGE, SEX, and exposure to water in FOUNTAINS or from BOTTLES.

DOSAGE ODDS RATIO 95% CONFIDENCE LIMITS

ICE CUBES 3.28 1.58-6.80
DRINKING 4.44 2.23-8.86
FOUNTAINS 0.40 0.20-0.78
Table 4

*
Wash their fruit and vegetables with water from the infected network.
†
Use, as well, ice cubes with their drinks and dishes.
‡
Drink water, too.
§
Only statistical significance variables are shown.
PHYSICAL-CHEMICAL AND MICROBIOLOGICAL ANALYSIS

WATER SAMPLES
Most of the samples gathered showed insufficient quantities of residual free
chlorine (between 0.10 and 0.15 mg/L).
In all cases, the results of microbiological analysis (detection of bacteria) were
negative.

STOOL CULTURES
There were no positive results.
DISCUSSION

• Although the epidemic curve suggests a common source for the outbreak, the
food hypothesis as a vehicle for infection does not seem probable. Due to the broad
distribution of the affected area, along many streets in all the neighbourhoods
mentioned, as well as the maximum increase of the incidence , two to three days after
(and due to beginning of the brief incubation period of most of food-borne diseases), it
seems unlikely such a fast distribution of contaminated food in such a big area.
On the other hand, the distribution of the tap-water network from the chlorinating tank
corresponds with the affected area.
• The geographic limitation of the outbreak to the mentioned neighbourhoods,
exclusively, allows us to reasonably reject the possibility of air-borne infection by
enteroviruses.
• The strong association detected between this illness and the exposure to the
tap-water of the network, points out that this is not a finding made by chance.
• The association is maintained considering different states of the sickness.
• Considering different dosages of exposition to the water of the network, dose-
response relationship is found.

CONCLUSIONS
• The cause of the studied outbreak had as a vehicle the human consumption of water.
• The only type of water involved in the epidemy was the one that came from the
public network supply.
• The chlorination of water supplies with modern systems (gas chlorine, daily
chlorine determinations) does not stop on its own and in determined circumstances
the infection of the network, the consumption of chlorine, and the following
appearance of outbreaks like the one described here, which enforces the need to
maintain sensitive, fast, and effective Alert System in Public Health, that will enable
healthcare professionals to cope with risk situations as much us to adopt measures to
limit the effects.

BIBLIOGRAFIA
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