On Monday 15 January 2007, a municipality in Denmark received the first of several complaints from citizens who reported severe diarrhoea and vomiting over the weekend. Over the same period, the drinking water in many houses was reported to be discoloured and of unusual smell and taste. The local authorities immediately prohibited any use of the water - except for toilet flushing - in the entire area supplied with untreated drinking water from the local waterworks, which involved 5,802 citizens and a number of companies (Figure 1). The citizens in the area were warned by the police and through radio broadcasts.
To reveal the nature and the geographical spread of the suspected water contamination, water samples for microbiological and chemical analyses were systematically collected from the water distribution system across the whole area supplied from the local waterworks. The water samples were collected at the waterworks itself, from major water pipelines and wells, and from tap water in private houses and companies. High concentrations of faecal indicator bacteria (primarily presumptive coliform counts and���Escherichia coli) and endotoxins in the water samples indicated a massive faecal contamination of a part of the water distribution system, while other parts of the distribution system appeared not to be affected. On the basis of the geographical distribution of indicator bacteria, and the technical information about directions of the water flow in the different sections of the water distribution system, the area suspected to be contaminated was systematically reduced step by step during the next days.
Based on the analyses of 530 water samples collected at 200 different sites, the area finally considered to be affected by the water contamination was defined on 26 January 2007 (indicated with a red line in Figure 1). This area comprised 177 households with 450 residents and several companies, among which six dealt with food. Restrictions on water use were maintained in this area, while the water was released for normal use in the area that was not considered to be contaminated.
Gastrointestinal illness
A line-list of patients with gastrointestinal illness associated with the water contamination was established on the basis of notifications from general practitioners, enquiries made to the medical health officer, patients seeking advice from the emergency medical service, and patients contacting an ad hoc telephone ���hotline��� established by the local authorities. Additional information was collected during a house-to-house questionnaire survey conducted on 16 January among 20 households in the most severely affected street. Stool samples were examined at the Department of Bacteriology, Mycology and Parasitology, and the Department of Virology, Statens Serum Institut, Copenhagen. A case of acute gastroenteritis was defined as a person with diarrhoea, vomiting and/or abdominal pain/cramps with fever. To verify whether reported cases met the case definition, and to confirm the geographical extent of gastrointestinal illness associated with the water contamination, patients on the line-list were contacted by telephone and/or postal questionnaires.
By the end of February 2007, 140 cases had been registered: 110 were residents of the area that was judged to be contaminated on the basis of the environmental investigations, 12 were shoppers or employees at the food companies in the area, and 18 affected people came from outside the contaminated area. The epidemic curve for cases among residents in the contaminated area with known date of illness onset is shown in Figure 2. No new cases in the contaminated area were registered after 24 January.
Cases were largely confined to the contaminated area. A total of 24% of the residents of the contaminated area were registered with gastrointestinal illness, compared with 0.3% in the other sections of the waterworks��� supply area (relative risk 73; 95% CI 44-127). From the most severely affected street in the contaminated area, 43% of residents were reported to have fallen ill. Four patients were temporarily admitted to hospital.
Microbiological results
By the end of February 2007, stool samples from 139 patients affected by the outbreak (including 99 patients who met the case-definition criteria) had been examined with respect to gastrointestinal bacteria, viruses and parasites. Among these, 77 patients (43 cases) had one or more samples that tested positive, including 23 patients with 2-5 different pathogenic gastrointestinal organisms (Table). Not all samples were tested for the entire range of pathogens identified. Further microbiological testing and genotyping of the samples are being undertaken.
Technical assessment and intervention
Technical and microbiological investigations of the water indicated that the most probable cause of the contamination was the combination of a technical and a human error at a local sewage treatment facility, which allowed at least 27 m3���of partially filtered waste water to enter into the drinking water system in the period between 12 and 14 January 2007. The two pipelines were separated, and the exact circumstances of the incident that allowed the backflow of the sewage water remain to be revealed. The conclusion of the technical investigations was supported by the large variety of gastrointestinal pathogens found in the stool samples, which corroborated that the contamination was due to backflow of grossly contaminated sewage water rather than, for example, surface water or sewage from only a few households. The sewage treatment plant receives sewage from a population of approximately 40,000, as well as industrial enterprises, food production establishments and a hospital.
Flushing of the area���s distribution system was initiated immediately and sustained for several weeks. As faecal indicator bacteria were still found in the drinking water after two weeks of sustained flushing, the distribution system was subsequently disinfected by chlorination on 10 and 11 February. After another two days of flushing, the drinking water was released for normal use, but recommended for drinking still only after boiling. By 12 March, the boiling restrictions were lifted for the majority of households, since by then the environmental water samples from the distribution system had fulfilled the quality criteria for untreated drinking water as defined by the Danish Ministry of Environment [3].
Commentary
The handling of the outbreak called for interdisciplinary cooperation and the epidemiological investigations supported the technical and water-microbiological analyses. Geographical information systems were used to define the contaminated area, and the 18 episodes of illness reported outside of the contaminated area (Figure 1) probably represent sporadic illness or could be associated with the outbreak in a way that was not investigated, for example by secondary transmission.
Although the drinking water supply in Denmark is primarily from untreated ground water, disease cases are rarely registered in connection with incidents of contamination [1,2]. The outbreak described was unusual, partly because of the high morbidity among the exposed citizens, and partly because of the extraordinary complexity of positive microbiological findings; a recent review of disease outbreaks caused by contaminated drinking water in the United States from 2003 to 2004 reported that in only two out of 25 outbreaks with known aetiology more than one microorganism was detected [4]. The consequences were considerable for the affected families, but also for the food companies, which were not allowed to resume production until the middle of February.


{'answer_start': [128], 'text': ['diarrhoea and vomiting']}