Improving waterborne disease outbreak investigations.

This article is a summary of discussions held and recommendations made at a workshop for the investigation of waterborne disease outbreaks in Chapel Hill, North Carolina, December 7-8, 1998. Suspected waterborne outbreaks in the United States are primarily investigated by state and local public health officials who may infrequently conduct enteric disease outbreak investigations. Thus, it is important that officials have a formal plan to ensure that epidemiological studies are methodologically sound and that effective collaboration occurs among the epidemiologists, scientists, and engineers who will conduct the investigations. Laboratory support to analyze water samples and clinical specimens should be arranged well in advance of when services may be needed. Enhanced surveillance activities can help officials recognize additional outbreaks and initiate investigations in a timely manner. Epidemiologists should pay more attention early in the investigation to study design, questionnaire development, and sources of bias, especially recall bias, that may affect the interpretation of observed associations. Improved investigations can increase our knowledge about important etiological agents, water systems deficiencies, and sources of water contamination so that waterborne outbreaks can be more effectively prevented.