CRYPTOSPORIDIOSIS OUTBREAK EDUCATION AND ACTION PLAN A MODEL DOCUMENT DEVELOPED BY COMMUNITIES IN JOHNSON COUNTY, KANSAS AND THE SURROUNDING AREA

Transcription

1 CRYPTOSPORIDIOSIS OUTBREAK EDUCATION AND ACTION PLAN A MODEL DOCUMENT DEVELOPED BY COMMUNITIES IN JOHNSON COUNTY, KANSAS AND THE SURROUNDING AREA Spring 2012

2 Table of Contents Definition... 3 Symptoms..3 Causes.. 3 Risk Factors...4 Complications...4 Cause for Action...5 Public Education..5 Additional Educational Materials 5-6 Inter-Agency Communications Plan 7 Inter-Agency Response Plan.8 Information/Assistance Provided by Johnson County KS, Department Of Health and Environment 8 Media Response Statement 9 Other Recreational Water Illnesses.10 Recommended Treatment for a Crypto Contaminated Pool 11 Participating Professionals and Agencies..14 Resources, References, and Documents...15 KCMAC Approved Informational Poster..16 2

3 Definition Cryptosporidium infection (cryptosporidiosis) is a gastrointestinal disease whose primary symptom is diarrhea. The illness begins when the tiny cryptosporidium parasites enter your body and travel to your small intestine. Cryptosporidium (krip-toe-spo-rid-ee-um) then begins its life cycle inside your body burrowing into the walls of your intestines and then later being shed in your feces. In most healthy people, a cryptosporidium infection produces a bout of watery diarrhea and the infection usually goes away within a week or two. If you have a compromised immune system, a cryptosporidium infection can become life-threatening without proper treatment. You can help prevent cryptosporidium by practicing good hygiene and by avoiding drinking water that hasn't been boiled or filtered. By Mayo Clinic staff 1 Symptoms The first signs and symptoms usually appear two to seven days after infection with cryptosporidium and may include: Watery diarrhea Dehydration Weight loss Stomach cramps or pain Fever Nausea Vomiting Symptoms may last for up to two weeks, though they may come and go sporadically for up to a month, even in people with healthy immune systems. Some people with cryptosporidium infection may have no symptoms. By Mayo Clinic staff 1 Causes Cryptosporidium infection begins when you ingest the cells of one of nearly a dozen species of the one-celled cryptosporidium parasite. The Cryptosporidium parvum (C. parvum) species is responsible for the majority of infections in humans. These parasites then travel to your intestinal tract, where they settle into the walls of your intestines. Eventually, more cells are produced and shed in massive quantities into your feces, where they are highly contagious. You can become infected with cryptosporidium by touching anything that has come in contact with contaminated feces. Methods of infection include: Swallowing or putting something contaminated with cryptosporidium into your mouth Drinking water contaminated with cryptosporidium Swimming in water contaminated with cryptosporidium and accidentally swallowing some of it Eating uncooked food contaminated with cryptosporidium Touching your hand to your mouth if your hand has been in contact with a contaminated surface or object Having close contact with other infected people or animals especially their feces which can allow the parasite to be transmitted from your hands to your mouth 3

4 If you have a compromised immune system from HIV/AIDS, you're more susceptible to illness from cryptosporidium than is a person with a healthy immune system. People with HIV/AIDS can develop severe symptoms and a chronic, persistent form of disease that may be difficult to treat. -By Mayo Clinic staff 1 Hardy Parasites Cryptosporidium is one of the most common causes of diarrhea in humans. This parasite is difficult to eradicate because it's resistant to many chlorine-based disinfectants and can't be effectively removed by many filters. Cryptosporidium can also survive in the environment for many months at varying temperatures, though the parasite can be destroyed by freezing or boiling. The Center for Disease Control states that It has a tough outer shell that allows it to survive for a long time in the environment. It can survive for days in properly chlorinated pools. Risk Factors People who are at increased risk of developing cryptosporidiosis include: Those who are exposed to contaminated water Children, particularly those wearing diapers, who attend child care centers Parents of infected children Child care workers Animal handlers Those who engage in oral-to-anal sexual activity International travelers, especially those traveling to developing countries Backpackers, hikers and campers who drink untreated, unfiltered water Swimmers who swallow water in pools, lakes and rivers People who drink water from shallow, unprotected wells -By Mayo Clinic staff 1 Complications Complications of cryptosporidium infection include: Malnutrition resulting from poor absorption of nutrients from the intestinal tract (malabsorption) Severe dehydration Significant weight loss (wasting) Inflammation of a bile duct - the passage between the liver, gallbladder and small intestine Inflammation of the gallbladder, liver or pancreas The cryptosporidium infection itself isn't life-threatening. However, if you've had a transplant or if you have a weakened immune system, developing complications can be dangerous. -By Mayo Clinic staff 1 Cause for Action Lessons learned from the August, 2011 Johnson County, KS area-wide outbreak of cryptosporidiosis precipitated metro area parks and recreation professionals to form a task force to review the existing countywide outbreak response procedures and to develop a plan to be used on a go forward basis. The Center for Disease Control reminds us that you share the water and the germs in it with every 4

5 person who enters the pool. This means that just one person with diarrhea can easily contaminate the water. Chlorine kills RWI germs in the water, but it needs time to work. Without your help, even the best maintained pools can spread germs. Public Education First and foremost, all agencies have agreed to provide the same public education materials to their users. This will be done by including information in seasonal activity guides and handouts/posters at all facilities, as well as distribution to season pass holder and agency specific websites. Additional information can be found at including down-loadable handouts and posters. At a minimum, the following should be posted at all facilities: Please do not swim when you have diarrhea. You can spread germs in the water and make other people sick, Please do not swallow pool water. Avoid getting water in your mouth. Please practice good hygiene. Shower with soap and water before swimming and wash your hands after using the toilet or changing diapers. Germs on your body end up in the water. Please take children on bathroom breaks or check diapers often. Waiting to hear I have to to may mean that it s too late. Please change diapers in a bathroom or a diaper-changing area and not at poolside. Germs can be spread to surfaces and objects in and around the pool. Please wash your child thoroughly with soap and water before swimming. Invisible amounts of fecal matter can end up in the pool. Additional Educational Resource Materials on Cryptosporidium Brochures - Healthy Swimming - English Healthy Swimming - Spanish Before you go to the Beach Fact Sheet - Crypto and Swimming Pools Also have fact sheets for: Giardia, Hot Tub Rash, Legionella, MRSA, Swimmer s Ear, and Swimmer s Ear Prevention Tips Podcast - CDC Kidtastics - Getting Along Swimmingly Ask CDC: It s OK to Go in the Water Summer Swimming Safety, 1 min. Summer Swimming Safety, 4:11 min. Posters - Six P-L-E-As for Protection Against RWI Six Steps for Healthy Swimming Diarrhea and Swimming Don t Mix 5

6 Why Would You Drink the Water You Swim In? Why Not Wash Your Hands? There Are Some Things You Would Rather Not Share Bathroom Break Wanted - Saggy Diapers Wash Your Baby Video - In the Swim of Things NOTE - Alcohol-based hand gels and sanitizers do not kill Cryptosporidium (or Crypto ) so they do not help stop the spread of Crypto. The appendix of this plan includes a poster approved by the Kansas City Metro Aquatics Council that will be made available to participating agencies. 6

7 Inter-Agency Communications Plan By Nathan Nogelmeier, City of Fairway, KS When the Johnson County Departments of Public Health and/or Environment confirm a swimming pool related case of Cryptosporidiosis at: A. Private/Semi-private Facility If either the Johnson County Department of Public Health (JCPH) or the Johnson County Department of Environmental (JCDE) confirm a case of Cryptosporidiosis with a potential link to a private/semi-private swimming pool, located within a Johnson County city, the confirming Department will notify the appropriate City personnel as soon as reasonably possible. The confirming Department will inform City staff of the approximate location (nearest major intersection) of the confirmed case. Once notified, City staff will distribute the information as soon as reasonably possible to adjacent cities (if applicable) so enhanced education/awareness efforts can be implemented at each facility. B. Public/Municipal Facility If either the Johnson County Department of Public Health (JCPH) or the Johnson County Department of Environmental (JCDE) confirm a case of Cryptosporidiosis with a potential link to a public/municipal swimming pool, located within a Johnson County city, the confirming Department will notify the appropriate City personnel as soon as reasonably possible. The confirming Department will then notify ALL public/municipal facilities located in Johnson County as soon as reasonably possible so enhanced education/awareness efforts can be implemented at all public/municipal facilities in the county. When a public or municipal facility is informed by a patron that the patron has a physician confirmed case of Cryptosporidiosis and has recently utilized the facility- If a public or municipal facility is informed by a patron that he/she has a physician confirmed case of Cryptosporidiosis, agency personnel will notify JDPH and JCDE as soon as reasonably possible to verify that a physician confirmed case has been reported. Agency personnel will notify, as soon as reasonably possible, adjacent cities (if applicable) so enhanced educations/awareness efforts can be implemented at each facility. 7

8 Inter-Agency Response Plan After a meeting with the Johnson County Department of Health and Environment representatives, the park and recreation professionals working on the task force felt that in the process of due diligence, it would be beneficial to each agency to establish an Inter-Agency Response Plan to be implemented in the event of a confirmed Crypto (or other applicable contagious disease) diagnosis or outbreak. The plan is as follows: Stage One (one agency reporting) Case-confirmed facility(ies) implements closure and hyper chlorination procedures per CDC guidelines. Agency reopens when chemicals return to normal. All agencies enhance education/awareness efforts. Stage Two (two or more agencies reporting with multiple cases; County acknowledges an Outbreak ) Case-confirmed facilities implement closure and hyper chlorination procedures per CDC guidelines. All agencies enhance education/awareness efforts. Stage Three (Mass closure recommended by County) Agencies will implement closure and initiate hyperchlorination procedures per CDC guidelines. Agency facilities will remain closed for a length of time to be determined by the participating agencies, in consultation with the County. All agencies will enhance education/awareness efforts. Information/Assistance Provided by Johnson County KS, Department of Health and Environment By Ryan Lester, Johnson County Department of Health and Environment and Christy Humerickhouse, City of Mission, KS Representatives from the Johnson County Department of Health and Environment were invited to participate in the outbreak and response plan development process. These representatives shared with the park and recreation professionals that they follow the Kansas Department of Health and Environment standards and protocols when instructing agencies or groups on how to respond to a confirmed case of Crypto. The Johnson County Department of Health and Environment takes every confirmed and/or suspected Recreational Water Illness case very seriously, regardless of the specific RWI. The Johnson County Department of Health and Environment communicated to the park and recreation professionals that the health department s role in a Crypto outbreak event will be that of advisory. Furthermore, they will follow the procedure that every confirmed case or outbreak is situational and that their advised response procedures will be case/outbreak dependent. The chances of the health department requiring a county-wide shutdown at any point is highly unlikely. 8

9 Media Response Statement By Lauren Ozburn, City of Lenexa, KS Key Messages: The (your agency here) is dedicated to the health and safety the community. The KC Metro Area Communities Cryptosporidiosis Outbreak Prevention and Response Plan is not required to be adopted by any governing agency; however, (our agency) or (many metro agencies) have adopted this pro-active plan of action to promote the health and safety of our patrons and community. General Information: - RWI s can make people sick - Crypto is a parasite that affects the gastrointestinal system - Crypto is carried in feces - Crypto can be spread long before and long after symptoms start - It takes time for chlorine to work on germs like Crypto; it takes everyone to help protect the pool water. - If you, or one of your family members, have diarrhea, go to the doctor and have a crypto specific test taken. The only way to know if you have it is to ask for the appropriate tests. Talking Points: What you (members of the public) can do - Steps to prevent: Don t swim with diarrhea or- if you have had diarrhea within the last 2 weeks Don t swallow pool water Wash your body before swimming Check diapers often and change in restroom Take frequent bathroom breaks What the agency will do - Steps to prevent: Water chemistry is monitored frequently throughout the day and chemicals are kept at a recommended level. Rules will be enforced to protect water safety. If one or two agencies are notified of a confirmed case: Affected agency(s) will close for the specified period of time recommended by the JOCO health department (typically 12 hours) and elevate chemical levels for that period of time. Agency(s) will re-evaluate with the health department after the specified period of time to determine opening status and procedures. If more than two agencies are notified of confirmed cases: To protect the safety of the public at large, the JOCO Health Dept. has issued a strong recommendation for all pools in the county to close and implement hyperchlorination procedures. 9

10 The recommended period of closure is ( ) days. We will follow the recommendations of the JOCO Health Dept. to maintain safety standards. Other Recreational Water Illnesses to Be Aware Of From the Center for Disease Control Giardia 3 (gee-are-dee-uh) is a germ that causes diarrhea. This germ is found in the fecal matter of a person who has been infected by Giardia. It has a tough outer shell that allows it to survive for up to 45 minutes, even in properly chlorinated pools. The disease caused by infection with the germ Giardia is called giardiasis. Giardia is microscopic, so it can t be seen with the naked eye. Legionella 4 (LEE-juh-nell-a) is a germ that can cause a type of pneumonia called legionellosis, more commonly known as Legionnaires disease. Legionella is microscopic, so it can t be seen with the naked eye. Staphylococcus aureus 5 ("staph") is a germ that often lives in the nose or on the skin of healthy people. MRSA, short for methicillin-resistant Staphylococcus aureus, is a type of staph germ that is resistant to certain antibiotics. In the community, most MRSA infections are skin infections (pustules, boils) that may be: Mistaken for spider bites Red, swollen, painful, warm to the touch, and have pus or other drainage Accompanied by a fever MRSA does not survive long in recreational water (for example, pools or hot tubs) that has proper disinfectant (chlorine) and ph levels. There have been no reports of MRSA spreading through contact with recreational water. However, MRSA can be spread at recreational water facilities and other places by direct and indirect contact with infected persons. Direct contact can happen when you touch another person s MRSA infection. Indirect contact can happen when you share items (like towels or razors) or touch surfaces (like hand rails or locker room benches) contaminated with MRSA. MRSA is most likely to spread when it comes into contact with an uncovered cut or scrape. 10

11 Recommended Treatment for a Crypto Contaminated Pool 2 Center for Disease Control Hyperchlorination to Kill Cryptosporidium* Cryptosporidium (or Crypto ) is a chlorine resistant parasite, so even well-maintained pools, water parks, and interactive fountains can be a venue to spread Crypto among swimmers. If an outbreak of Crypto infections occurs in your community, the health department might ask you to hyperchlorinate. Additionally, to help keep Crypto levels in the water low, you might choose to hyperchlorinate regularly (for example, weekly). If necessary, consult an aquatics professional to determine and identify the feasibility, practical methods, and safety considerations before attempting to hyperchlorinate. Step 1: Close the pool to swimmers. If you have multiple pools that use the same filtration system all pools will have to be closed to swimmers and hyperchlorinated. Do not allow anyone to enter the pool(s) until hyperchlorination is completed. Step 2: Raise the free chlorine concentration (see table below) and maintain ph at 7.5 or less and the temperature at 77 F (25 C) or higher. Cryptosporidium Inactivation Time for Diarrheal Contamination Chlorine Levels (mg/l) Disinfection Time ,300 minutes (255 hours) ,530 minutes (25.5 hours) minutes (12.75 hours) Step 3: Achieve a contact time (CT) inactivation value of 15,300 to kill Crypto. The CT inactivation value refers to the concentration of free chlorine in parts per million (ppm) multiplied by time in minutes at a specific ph and temperature (see footnote for guidance if chlorine stabilizer is used). Step 4: Confirm that the filtration system is operating while the water reaches and is maintained at the proper chlorine level for disinfection. Step 5: Backwash the filter thoroughly after reaching the CT inactivation value. Be sure the effluent is discharged directly to waste and in accordance with state or local regulations. Do not return the backwash through the filter. Where appropriate, replace the filter media. Step 6: Allow swimmers back into the water only after the required CT inactivation value has been achieved and the free chlorine and ph levels have been returned to the normal operating range allowed by the state or local regulatory authority.** *Check for existing guidelines from your local or state regulatory agency before use. CDC recommendations do not replace existing state or local regulations or guidelines. 11

12 Many conventional test kits cannot measure free chlorine levels this high. Use chlorine test strips that can measure free chlorine in a range that includes ppm or mg/l (such as those used in the food industry) or make dilutions for use in a standard DPD test kit using chlorine-free water. Shields JM, Hill VR, Arrowood MJ, Beach MJ. Inactivation of Cryptosporidium parvum under chlorinated recreational water conditions. J Water Health 2008;6(4): Crypto CT inactivation values are based on killing 99.9% of Crypto. This level of Crypto inactivation cannot be reached in the presence of 50 ppm chlorine stabilizer, even after 24 hours at 40 ppm free chlorine, ph 6.5, and a temperature of 77 F (25 C). Extrapolation of these data suggest it would take approximately 30 hours to kill 99.9% of Crypto in the presence of 50 ppm or less cyanuric acid, 40 ppm free chlorine, ph 6.5, and a temperature of 77 F (25 C) or higher. Shields JM, Arrowood MJ, Hill VR, Beach MJ. The effect of cyanuric acid on the chlorine inactivation of Cryptosporidium parvum in 20 ppm free chlorine. J Water Health 2009; 7(1): ** CDC does not recommend testing the water for Crypto after hyperchlorination is completed. Although hyperchlorination destroys Crypto s infectivity, it does not necessarily destroy the structure of the parasite. The CDC s fecal response plan can be found at: 12

13 CITY OF RESOLUTION NO A RESOLUTION OF THE GOVERNING BODY OF THE CITY OF, KANSAS, ADOPTING THE REGIONAL CRYPTOSPORIDIOSIS OUTBREAK EDUCATION AND ACTION PLAN WHEREAS, each year, nearly 1,000,000 visits are made to publicly owned swimming pools in Johnson County, KS and more than 2,000,000 visits are made to publicly owned swimming pools in the Kansas City Metro area; and WHEREAS, Parks & Recreation professionals across the Kansas City Metro area recognize the importance of providing opportunities for safe and healthy swimming; and WHEREAS, preventing Cryptosporidiosis and other Recreational Water Illness outbreaks through public education and awareness efforts is a priority for Parks & Recreation professionals and Public Health officials; and WHEREAS, lessons learned from a recent community-wide cryptosporidiosis outbreak underscore the importance of pre-planning with good communication and rapid, consistent action. NOW, THEREFORE, BE IT RESOLVED BY THE GOVERNING BODY OF THE CITY OF, KANSAS, that the attached Cryptosporidiosis Outbreak Education and Action Plan is adopted as an effective way to prepare for, and respond to, a regional outbreak of Cryptosporidiosis. Adopted by the Governing Body this day of, APPROVED AND SIGNED by the Mayor this day of, ATTEST: City Clerk Mayor APPROVED AS TO FORM: City Attorney 13

14 Participating Park and Recreation Professionals and Agencies Armstrong, Jim Johnson Co. (KS). Parks & Recreation Dist Casper, Caroline Water s Edge Aquatic Design ccasper@wedesignpools.com Claxton, Chris City of Leawood, KS ChrisC@leawood.org Curran, Kim City of Leawood, KS KimC@leawood.org Dean, David City of Lee s Summit, MO ddean@cityofls.net Engel, Chris City of Prairie Village, KS cengel@pvkansas.com Ford, Beau City of Spring Hill, KS fordb@springhillks.com Gibbs, Jimmy City of Lawrence, KS jgibbs@lawrenceks.org Goin, Jason Spring Hill (KS) Recreation Comm. jasong@springhillrec.org Grosdidier, Dawn City of Lenexa, KS dgrosdidier@lenexa.com Harger, Melinda Water s Edge Aquatic Design mharger@wedesignpools.com Hayden, Susan City of Merriam, KS shayden@merriam.org Holopirek, Adraina City of Gardner, KS aholopirek@gardnerkansas.gov Humerickhouse, Christy City of Mission, KS chumerickhouse@missionks.org Keenan, Sean City of Shawnee, KS skeenan@cityofshawnee.org Knabe, Konni City of Olathe, KS KKnabe@olatheks.org Lecuru, Tonya City of Shawnee, KS tlecuru@cityofshawnee.org Lester, Ryan Johnson Co. (KS) Government ryan.lester@jocogov.org Letts, Darla Blue Valley Recreation Comm.(KS) dletts@bluevalleyrec.org Montemayor, Jim Commercial Aquatics jim@commercialaquatics.com Nogelmeier, Nathan City of Fairway, KS nnogelmeier@fairwaykansas.org Ozburn, Lauren City of Lenexa, KS lozburn@lenexa.com Pollock, Shelly City of Leawood, KS ShellyP@leawood.org Smith, Jende City of St. Joseph, MO jsmith@ci.st-joseph.mo.us Snook, Joe City of Lee s Summit, MO jsnook@cityofls.net Tausz, Nancy Johnson Co. (KS) Government nancy.tausz@jocogov.org Toben, Bryan City of Overland Park, KS bryan.toben@opkansas.org 14

15 Resources, References, and Documents