CRYPTOSPORIDIOSIS OUTBREAK

EDUCATION AND ACTION PLAN

A MODEL DOCUMENT DEVELOPED BY COMMUNITIES IN JOHNSON COUNTY, KANSAS AND THE SURROUNDING AREA

Spring 2012

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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

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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

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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

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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

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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

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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 http://www.cdc.gov/healthywater/swimming/ 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 - http://www.cdc.gov/healthywater/swimming/resources/brochures.html

○ Healthy Swimming - English

○ Healthy Swimming - Spanish

○ Before you go to the Beach

Fact Sheet -

http://www.cdc.gov/healthywater/pdf/swimming/resources/cryptosporidiumfactsheet.pdf

○ 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 - http://www/cdc.gov/healthywater/swimming/resources/podcasts.html

○ 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 - http://www.cdc.gov/healthywater/swimming/resources/poster.html

○ Six “P-L-E-As” for Protection Against RWI

○ Six Steps for Healthy Swimming

○ Diarrhea and Swimming Don’t Mix

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○ 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 - http://www.cdc.gov/cdctv/SwimOfThings/

○ 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.

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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.

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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”.

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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.

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● 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.

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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

1.0 15,300 minutes (255 hours)

10.0 1,530 minutes (25.5 hours)

20.0 † 765 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.

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† 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 20 - 40 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):513–20.

§ 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):109–114.

** 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:

http://www.cdc.gov/healthywater/pdf/swimming/pools/hyperchlorination-to-kill-cryptosporidium.pdf

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CITY OF ____________________

RESOLUTION NO. ______- 2012

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 ______, 2012.

APPROVED AND SIGNED by the Mayor this ___day of ______, 2012.

_________________________________________

Mayor

ATTEST:

_____________________________________

City Clerk

APPROVED AS TO FORM:

_____________________________________

City Attorney

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Participating Park and Recreation Professionals and Agencies

Armstrong, Jim Johnson Co. (KS). jim.armstrong@gocogov.org 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

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Resources, References, and Documents

1. http://www.mayoclinic.com/health/AboutThisSite/AM00057

2. http://www.cdc.gov/healthywater/pdf/swimming/pools/hyperchlorination-to-kill-

cryptosporidium.pdf

3. http://www.cdc.gov/healthywater/pdf/swimming/rwi/illness/giardia.html

4. http://www.cdc.gov/healthywater/pdf/swimming/rwi/illness/Legionella.html

5. http://www.cdc.gov/healthywater/pdf/swimming/rwi/illness/mrsa.html