@article{bloch_faulkner_hilborn_wismer_martin_rhea_2023, title={Geographic Variability, Seasonality, and Increase in ASPCA Animal Poison Control Center Harmful Blue-Green Algae Calls-United States and Canada, 2010-2022}, volume={15}, ISSN={["2072-6651"]}, url={http://dx.doi.org/10.3390/toxins15080505}, DOI={10.3390/toxins15080505}, abstractNote={Harmful cyanobacteria (blue-green algae) exposures can cause illness or death in humans and animals. We characterized American Society for the Prevention of Cruelty to Animals (ASPCA) Animal Poison Control Center (APCC) harmful blue-green algae (HBGA) call data, compared it to a measure of harmful algal bloom public awareness, and considered its suitability as a public health information source. ASPCA APCC dog and cat “HBGA exposure” calls made 1 January 2010–31 December 2022 were included. We calculated annual HBGA call percentages and described calls (species, month, origin, exposure route). We characterized public awareness by quantifying Nexis Uni® (LexisNexis Academic; New York, NY, USA)-indexed news publications (2010–2022) pertaining to “harmful algal bloom(s)”. Call percentage increased annually, from 0.005% (2010) to 0.070% (2022). Of 999 HBGA calls, 99.4% (n = 993) were dog exposures. Over 65% (n = 655) of calls were made July–September, largely from the New England (n = 154 (15.4%)) and Pacific (n = 129 (12.9.%)) geographic divisions. Oral and dermal exposures predominated (n = 956 (95.7%)). Harmful algal bloom news publications increased overall, peaking in 2019 (n = 1834). Higher call volumes in summer and in the New England and Pacific geographic divisions drove HBGA call increases; public awareness might have contributed. Dogs and humans have similar exposure routes. ASPCA APCC HBGA call data could serve as a public health information source.}, number={8}, journal={TOXINS}, publisher={MDPI AG}, author={Bloch, Rebecca A. and Faulkner, Grace and Hilborn, Elizabeth D. and Wismer, Tina and Martin, Nicole and Rhea, Sarah}, year={2023}, month={Aug} }
 @article{wu_hilborn_schaeffer_urquhart_coffer_lin_egorov_2021, title={Acute health effects associated with satellite-determined cyanobacterial blooms in a drinking water source in Massachusetts}, volume={20}, ISSN={["1476-069X"]}, url={https://doi.org/10.1186/s12940-021-00755-6}, DOI={10.1186/s12940-021-00755-6}, abstractNote={Abstract}, number={1}, journal={ENVIRONMENTAL HEALTH}, author={Wu, Jianyong and Hilborn, Elizabeth D. and Schaeffer, Blake A. and Urquhart, Erin and Coffer, Megan M. and Lin, Cynthia J. and Egorov, Andrey I}, year={2021}, month={Jul} }
 @article{deflorio-barker_egorov_smith_murphy_stout_ghio_hudgens_messier_maillard_hilborn_2021, title={Environmental risk factors associated with pulmonary isolation of nontuberculous mycobacteria, a population-based study in the southeastern United States}, url={http://dx.doi.org/10.1016/j.scitotenv.2020.144552}, DOI={10.1016/j.scitotenv.2020.144552}, abstractNote={The prevalence of pulmonary nontuberculous mycobacteria (NTM) disease is increasing in the United States. Associations were evaluated among residents of central North Carolina between pulmonary isolation of NTM and environmental risk factors including: surface water, drinking water source, urbanicity, and exposures to soils favorable to NTM growth. Reports of pulmonary NTM isolation from patients residing in three counties in central North Carolina during 2006-2010 were collected from clinical laboratories and from the State Laboratory of Public Health. This analysis was restricted to patients residing in single family homes with a valid residential street address and conducted at the census block level (n = 13,495 blocks). Negative binomial regression models with thin-plate spline smoothing function of geographic coordinates were applied to assess effects of census block-level environmental characteristics on pulmonary NTM isolation count. Patients (n = 507) resided in 473 (3.4%) blocks within the study area. Blocks with >20% hydric soils had 26.8% (95% confidence interval (CI): 1.8%, 58.0%), p = 0.03, higher adjusted mean patient counts compared to blocks with ≤20% hydric soil, while blocks with >50% acidic soil had 24.8% (-2.4%, 59.6%), p = 0.08 greater mean patient count compared to blocks with ≤50% acidic soil. Isolation rates varied by county after adjusting for covariates. The effects of using disinfected public water supplies vs. private wells, and of various measures of urbanicity were not significantly associated with NTM. Our results suggest that proximity to certain soil types (hydric and acidic) could be a risk factor for pulmonary NTM isolation in central North Carolina.}, author={DeFlorio-Barker, Stephanie and Egorov, Andrey and Smith, Genee S. and Murphy, Mark S. and Stout, Jason E. and Ghio, Andrew J. and Hudgens, Edward E. and Messier, Kyle P. and Maillard, Jean-Marie and Hilborn, Elizabeth D.}, year={2021} }
 @article{rublee_sorensen_lemery_wade_sams_hilborn_crooks_2020, title={Associations Between Dust Storms and Intensive Care Unit Admissions in the United States, 2000–2015}, url={https://doi.org/10.1029/2020GH000260}, DOI={10.1029/2020GH000260}, abstractNote={Abstract}, journal={GeoHealth}, author={Rublee, C. S. and Sorensen, C. J. and Lemery, J. and Wade, T. J. and Sams, E. A. and Hilborn, E. D. and Crooks, J. L.}, year={2020}, month={Aug} }
 @article{outbreaks associated with untreated recreational water - california, maine, and minnesota, 2018-2019._2020, url={https://europepmc.org/articles/PMC7316318}, DOI={10.15585/mmwr.mm6925a3}, abstractNote={Outbreaks associated with fresh or marine (i.e., untreated) recreational water can be caused by pathogens or chemicals, including toxins. Voluntary reporting of these outbreaks to CDC's National Outbreak Reporting System (NORS) began in 2009. NORS data for 2009-2017 are finalized, and data for 2018-2019 are provisional. During 2009-2019 (as of May 13, 2020), public health officials from 31 states voluntarily reported 119 untreated recreational water-associated outbreaks, resulting at least 5,240 cases; 103 of the outbreaks (87%) started during June-August. Among the 119 outbreaks, 88 (74%) had confirmed etiologies. The leading etiologies were enteric pathogens: norovirus (19 [22%] outbreaks; 1,858 cases); Shiga toxin-producing Escherichia coli (STEC) (19 [22%]; 240), Cryptosporidium (17 [19%]; 237), and Shigella (14 [16%]; 713). This report highlights three examples of outbreaks that occurred during 2018-2019, were caused by leading etiologies (Shigella, norovirus, or STEC), and demonstrate the wide geographic distribution of such outbreaks across the United States. Detection and investigation of untreated recreational water-associated outbreaks are challenging, and the sources of these outbreaks often are not identified. Tools for controlling and preventing transmission of enteric pathogens through untreated recreational water include epidemiologic investigations, regular monitoring of water quality (i.e., testing for fecal indicator bacteria), microbial source tracking, and health policy and communications (e.g., observing beach closure signs and not swimming while ill with diarrhea).}, journal={MMWR. Morbidity and mortality weekly report}, year={2020}, month={Jun} }
 @article{surveillance for harmful algal bloom events and associated human and animal illnesses - one health harmful algal bloom system, united states, 2016-2018._2020, url={https://europepmc.org/articles/PMC7745959}, DOI={10.15585/mmwr.mm6950a2}, abstractNote={Harmful algal bloom events can result from the rapid growth, or bloom, of photosynthesizing organisms in natural bodies of fresh, brackish, and salt water. These events can be exacerbated by nutrient pollution (e.g., phosphorus) and warming waters and other climate change effects (1); have a negative impact on the health of humans, animals, and the environment; and damage local economies (2,3). U.S. harmful algal bloom events of public health concern are centered on a subset of phytoplankton: diatoms, dinoflagellates, and cyanobacteria (also called blue-green algae). CDC launched the One Health Harmful Algal Bloom System (OHHABS) in 2016 to inform efforts to prevent human and animal illnesses associated with harmful algal bloom events. A total of 18 states reported 421 harmful algal bloom events, 389 cases of human illness, and 413 cases of animal illness that occurred during 2016-2018. The majority of harmful algal bloom events occurred during May-October (413; 98%) and in freshwater bodies (377; 90%). Human and animal illnesses primarily occurred during June-September (378; 98%) and May-September (410; 100%). Gastrointestinal or generalized illness signs or symptoms were the most frequently reported (>40% of human cases and >50% of animal cases); however, multiple other signs and symptoms were reported. Surveillance data from harmful algal bloom events, exposures, and health effects provide a systematic description of these occurrences and can be used to inform control and prevention of harmful algal bloom-associated illnesses.}, journal={MMWR. Morbidity and mortality weekly report}, year={2020}, month={Dec} }
 @article{ghio_smith_deflorio-barker_messier_hudgens_murphy_maillard_stout_hilborn_2019, title={Application of diagnostic criteria for non-tuberculous mycobacterial disease to a case series of mycobacterial-positive isolates}, url={https://doi.org/10.1016/j.jctube.2019.100133}, DOI={10.1016/j.jctube.2019.100133}, abstractNote={The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have provided guidelines to assist in the accurate diagnosis of lung disease caused by nontuberculous mycobacteria (NTM). These microbiologic, radiographic, and clinical criteria are considered equally important and all must be met to make the diagnosis of NTM lung disease. To assess the significance of the three criteria, each was evaluated for its contribution to the diagnosis of NTM lung disease in a case series. Laboratory reports of any specimen positive for NTM isolation were collected between January 1, 2006 and December 31, 2010 at a university medical center. Medical records were reviewed in detail using a standardized form. The total number of patients with a culture from any site positive for NTM was 297 while the number from respiratory specimens during the same period was 232 (78%). Samples from two of these patients also yielded M. tuberculosis complex and were excluded. While 128 of the remaining 230 patients (55.7%) in the cohort met the microbiologic criterion for diagnosis of NTM lung disease, 151 (65.6%) and 189 (78.3%) met the radiologic and clinical criteria respectively. Only 78 patients (33.9%) met all three criteria provided by the ATS/IDSA for diagnosis of NTM lung disease. This evaluation reaffirms that defining NTM lung disease using either one or two of the criteria provided by the 2007 ATS/IDSA guidelines may significantly overestimate the number of cases of NTM lung disease. Based on the experience of defining NTM lung disease in this case series, recommendations for modification of the ATS/IDSA guidelines are provided which include expansion of both radiologic patterns and the list of symptoms associated with NTM lung disease.}, author={Ghio, Andrew J. and Smith, Genee S. and DeFlorio-Barker, Stephanie and Messier, Kyle P. and Hudgens, Edward and Murphy, Mark S. and Maillard, Jean-Marie and Stout, Jason E. and Hilborn, Elizabeth D.}, year={2019} }
 @article{emergency department visits for acute gastrointestinal illness after a major water pipe break in 2010._2019, url={https://doi.org/10.1097/EDE.0000000000001083}, DOI={10.1097/ede.0000000000001083}, abstractNote={
            Background:
            When a water pipe breaks, contaminants can enter the drinking water system and cause waterborne illnesses such as acute gastrointestinal illness. In May 2010, a major water pipe broke near Boston, MA, and a boil water order was issued to nearly two million residents.
          }, journal={Epidemiology (Cambridge, Mass.)}, year={2019}, month={Nov} }
 @article{outbreaks associated with treated recreational water - united states, 2000-2014._2018, url={https://europepmc.org/articles/PMC6048947}, DOI={10.15585/mmwr.mm6719a3}, abstractNote={Outbreaks associated with exposure to treated recreational water can be caused by pathogens or chemicals in venues such as pools, hot tubs/spas, and interactive water play venues (i.e., water playgrounds). During 2000-2014, public health officials from 46 states and Puerto Rico reported 493 outbreaks associated with treated recreational water. These outbreaks resulted in at least 27,219 cases and eight deaths. Among the 363 outbreaks with a confirmed infectious etiology, 212 (58%) were caused by Cryptosporidium (which causes predominantly gastrointestinal illness), 57 (16%) by Legionella (which causes Legionnaires' disease, a severe pneumonia, and Pontiac fever, a milder illness with flu-like symptoms), and 47 (13%) by Pseudomonas (which causes folliculitis ["hot tub rash"] and otitis externa ["swimmers' ear"]). Investigations of the 363 outbreaks identified 24,453 cases; 21,766 (89%) were caused by Cryptosporidium, 920 (4%) by Pseudomonas, and 624 (3%) by Legionella. At least six of the eight reported deaths occurred in persons affected by outbreaks caused by Legionella. Hotels were the leading setting, associated with 157 (32%) of the 493 outbreaks. Overall, the outbreaks had a bimodal temporal distribution: 275 (56%) outbreaks started during June-August and 46 (9%) in March. Assessment of trends in the annual counts of outbreaks caused by Cryptosporidium, Legionella, or Pseudomonas indicate mixed progress in preventing transmission. Pathogens able to evade chlorine inactivation have become leading outbreak etiologies. The consequent outbreak and case counts and mortality underscore the utility of CDC's Model Aquatic Health Code (https://www.cdc.gov/mahc) to prevent outbreaks associated with treated recreational water.}, journal={MMWR. Morbidity and mortality weekly report}, year={2018}, month={May} }
 @article{outbreaks associated with untreated recreational water - united states, 2000-2014._2018, url={https://europepmc.org/articles/PMC6023190}, DOI={10.15585/mmwr.mm6725a1}, abstractNote={Outbreaks associated with untreated recreational water can be caused by pathogens, toxins, or chemicals in fresh water (e.g., lakes, rivers) or marine water (e.g., ocean). During 2000-2014, public health officials from 35 states and Guam voluntarily reported 140 untreated recreational water-associated outbreaks to CDC. These outbreaks resulted in at least 4,958 cases of disease and two deaths. Among the 95 outbreaks with a confirmed infectious etiology, enteric pathogens caused 80 (84%); 21 (22%) were caused by norovirus, 19 (20%) by Escherichia coli, 14 (15%) by Shigella, and 12 (13%) by Cryptosporidium. Investigations of these 95 outbreaks identified 3,125 cases; 2,704 (87%) were caused by enteric pathogens, including 1,459 (47%) by norovirus, 362 (12%) by Shigella, 314 (10%) by Cryptosporidium, and 155 (5%) by E. coli. Avian schistosomes were identified as the cause in 345 (11%) of the 3,125 cases. The two deaths were in persons affected by a single outbreak (two cases) caused by Naegleria fowleri. Public parks (50 [36%]) and beaches (45 [32%]) were the leading settings associated with the 140 outbreaks. Overall, the majority of outbreaks started during June-August (113 [81%]); 65 (58%) started in July. Swimmers and parents of young swimmers can take steps to minimize the risk for exposure to pathogens, toxins, and chemicals in untreated recreational water by heeding posted advisories closing the beach to swimming; not swimming in discolored, smelly, foamy, or scummy water; not swimming while sick with diarrhea; and limiting water entering the nose when swimming in warm freshwater.}, journal={MMWR. Morbidity and mortality weekly report}, year={2018}, month={Jun} }
 @article{mcclung_roth_vigar_roberts_kahler_cooley_hilborn_wade_fullerton_yoder_et al._2018, title={Waterborne disease outbreaks associated with environmental and undetermined exposures to water - United States, 2013-2014.}, url={https://doi.org/10.1111/ajt.14607}, DOI={10.1111/ajt.14607}, abstractNote={Weekly/November 10, 2017/66(44);12221225 Waterborne disease outbreaks in the United States are associated with a wide variety of water exposures and are reported annually to CDC on a voluntary basis by state and territorial health departments through the National Outbreak Reporting System (NORS). A majority of outbreaks arise from exposure to drinking water1 or recreational water,2 whereas others are caused by an environmental exposure to water or an undetermined exposure to water. During 20132014, 15 outbreaks associated with an environmental exposure to water and 12 outbreaks with an undetermined exposure to water were reported, resulting in at least 289 cases of illness, 108 hospitalizations, and 17 deaths. Legionella was responsible for 63% of the outbreaks, 94% of hospitalizations, and all deaths. Outbreaks were also caused by Cryptosporidium, Pseudomonas, and Giardia, including six outbreaks of giardiasis caused by ingestion of water from a river, stream, or spring. Water management programs can effectively prevent outbreaks caused by environmental exposure to water from humanmade water systems, while proper pointofuse treatment of water can prevent outbreaks caused by ingestion of water from natural water systems. CDC analyzed data from waterborne disease outbreaks reported to NORS associated with environmental and undetermined exposures to water during 20132014. Outbreaks with an environmental exposure to water are not associated with a recreational water venue or drinking water system, but rather, are linked to other water types including water from cooling towers, industrial processes, agricultural processes, occupational settings, decorative or display settings (e.g., decorative fountains), and water consumed from natural sources such as backcountry streams.3 Outbreaks involving an undetermined exposure to water could not be definitively linked to a single type of water exposure because of association with multiple suspected or confirmed water types (e.g., both spa and drinking water systems) or because insufficient epidemiologic, laboratory, or environmental evidence was available to identify the exposure. All outbreaks with first illness onset during 20132014 reported by December 31, 2015 are included in this report. NORS defines a waterborne disease outbreak as the occurrence of a similar illness in two or more persons who are linked by time and location to a common water exposure. For each outbreak, data were collected regarding the number of ill persons, hospitalizations, and deaths, along with the sex, age group, symptoms, and duration of illness for persons affected by the outbreak. Results of epidemiologic and laboratory investigations are also reported, including the suspected or confirmed etiologic agent, the type of water to which patients were exposed, and the setting of the water exposure. During the analysis, predominant illness type was assigned, and water type was further categorized as a humanmade or natural water system. Humanmade water systems include infrastructure intended for water storage or recirculation, whereas natural water systems include raw water that might or might not be treated at the point of exposure. Waterborne disease outbreaks associated with environmental and undetermined exposures to water from prior years have been reported previously (https://www.cdc.gov/healthywater/surveillance/environmental/environ-water-surveillance-reports.html).}, journal={American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons}, author={McClung, R. Paul and Roth, David M. and Vigar, Marissa and Roberts, Virginia A. and Kahler, Amy M. and Cooley, Laura A. and Hilborn, Elizabeth D. and Wade, Timothy J. and Fullerton, Kathleen E. and Yoder, Jonathan S. and et al.}, year={2018}, month={Jan} }
 @article{erratum: "sanitary sewer overflows and emergency room visits for gastrointestinal illness: analysis of massachusetts data, 2006-2007"._2017, url={https://europepmc.org/articles/PMC5963573}, DOI={10.1289/ehp3143}, abstractNote={[This corrects the article DOI: 10.1289/EHP2048.].}, journal={Environmental health perspectives}, year={2017}, month={Dec} }
 @article{smith_messier_crooks_wade_lin_hilborn_2017, title={Extreme precipitation and emergency room visits for influenza in Massachusetts: a case-crossover analysis}, url={https://doi.org/10.1186/s12940-017-0312-7}, DOI={10.1186/s12940-017-0312-7}, abstractNote={Influenza peaks during the wintertime in temperate regions and during the annual rainy season in tropical regions - however reasons for the observed differences in disease ecology are poorly understood. We hypothesize that episodes of extreme precipitation also result in increased influenza in the Northeastern United States, but this association is not readily apparent, as no defined 'rainy season' occurs. Our objective was to evaluate the association between extreme precipitation (≥ 99th percentile) events and risk of emergency room (ER) visit for influenza in Massachusetts during 2002-2008.A case-crossover analysis of extreme precipitation events and influenza ER visits was conducted using hospital administrative data including patient town of residence, date of visit, age, sex, and associated diagnostic codes. Daily precipitation estimates were generated for each town based upon data from the National Oceanic and Atmospheric Administration. Odds ratio (OR) and 95% confidence intervals (CI) for associations between extreme precipitation and ER visits for influenza were estimated using conditional logistic regression.Extreme precipitation events were associated with an OR = 1.23 (95%CI: 1.16, 1.30) for ER visits for influenza at lag days 0-6. There was significant effect modification by race, with the strongest association observed among Blacks (OR = 1.48 (1.30, 1.68)).We observed a positive association between extreme precipitation events and ER visits for influenza, particularly among Blacks. Our results suggest that influenza is associated with extreme precipitation in a temperate area; this association could be a result of disease ecology, behavioral changes such as indoor crowding, or both. Extreme precipitation events are expected to increase in the Northeastern United States as climate change progresses. Additional research exploring the basis of this association can inform potential interventions for extreme weather events and influenza transmission.}, journal={Environmental health : a global access science source}, author={Smith, Genee S. and Messier, Kyle P. and Crooks, James L. and Wade, Timothy J. and Lin, Cynthia J. and Hilborn, Elizabeth D.}, year={2017} }
 @article{indices of iron homeostasis correlate with airway obstruction in an nhanes iii cohort._2017, url={https://europepmc.org/articles/PMC5529299}, DOI={10.2147/copd.s138457}, abstractNote={Cigarette smoking results in the accumulation of iron both systemically and locally, in the lung thereby causing imbalance in iron homeostasis. This disruption in iron homeostasis can be associated with oxidative stress and consequent tissue injury. Therefore, in this study, we tested the association between iron homeostasis and airway obstruction by examining a large cohort of smokers and non-smokers for relationships between 1) serum ferritin and iron concentrations and transferrin saturation and 2) forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and their ratio (FEV1/FVC). Data from the National Health and Examination Survey III were analyzed. The study population included persons aged 20 years and above with their following data recorded: race, gender, serum ferritin and iron concentrations, and transferrin saturation; the final sample number was 7,251. In the total population, Pearson correlation coefficients between 1) serum ferritin and iron concentrations and transferrin saturation and 2) FVC and FEV1 were significantly positive; whereas those between 1) serum ferritin concentrations and transferrin saturation and 2) FEV1/FVC were significantly negative. With separate analyses, serum ferritin concentrations demonstrated positive associations with FVC and FEV1 but an inverse relationship with FEV1/FVC in smokers and non-smokers. Serum ferritin levels increased with worsening airway obstruction among smokers, and its highest concentrations were found among those with the lowest values of FEV1/FVC ratio (<60%). Comparable to cigarette smokers, serum ferritin concentrations among non-smokers were greatest in those with the lowest FEV1/FVC ratio. Furthermore, elevated levels of serum iron and saturation of transferrin also corresponded with decreased FEV1/FVC ratio among non-smokers. Thus, we conclude that indices of iron homeostasis are associated with airway obstruction in both smokers and non-smokers.}, journal={International journal of chronic obstructive pulmonary disease}, year={2017}, month={Jul} }
 @article{sanitary sewer overflows and emergency room visits for gastrointestinal illness: analysis of massachusetts data, 2006-2007._2017, url={https://europepmc.org/articles/PMC5947952}, DOI={10.1289/ehp2048}, abstractNote={Background: Sanitary sewer overflows (SSOs) occur when untreated sewage is discharged into water sources before reaching the treatment facility, potentially contaminating the water source with gastrointestinal pathogens. Objectives: The objective of this paper is to assess associations between SSO events and rates of gastrointestinal (GI) illness in Massachusetts. Methods: A case-crossover study design was used to investigate association between SSO events and emergency room (ER) visits with a primary diagnosis of gastrointestinal (GI) illness in Massachusetts for 2006–2007. ER visits for GI were considered exposed if an SSO event occurred in the county of residence within three hazard periods, 0–4 d, 5–9 d, or 10–14 d, before the visit. A time-stratified bidirectional design was used to select control days for each ER visit on the same day of the week during the same month. Fixed effect logistic regression models were used to estimate the risk of ER visits following the SSO event. Results: During the study period, there were 270 SSO events for northeastern Massachusetts and 66,460 ER admissions with GI illness listed as the primary diagnostic code. The overall odds ratio (OR) for ER visits for GI illness was 1.09 [95% confidence interval (CI): 1.03, 1.16] in the 10–14 d period following an SSO event, with positive ORs for all age groups and for three of the four counties. The 0–4 d and 5–9 d periods following an SSO event were not associated with ER visits for GI illness overall, and associations by county or age were inconsistent. Conclusions: We demonstrated an association between SSO events and ER visits for GI illness using a case-crossover study design. In light of the aging water infrastructure in the United States and the expected increase in heavy rainfall events, our findings suggest a potential health impact associated with sewage overflows. https://doi.org/10.1289/EHP2048}, journal={Environmental health perspectives}, year={2017}, month={Nov} }
 @article{surveillance for waterborne disease outbreaks associated with drinking water - united states, 2013-2014._2017, url={https://europepmc.org/articles/PMC5679581}, DOI={10.15585/mmwr.mm6644a3}, abstractNote={Provision of safe water in the United States is vital to protecting public health (1). Public health agencies in the U.S. states and territories* report information on waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS) (https://www.cdc.gov/healthywater/surveillance/index.html). During 2013-2014, 42 drinking water-associated† outbreaks were reported, accounting for at least 1,006 cases of illness, 124 hospitalizations, and 13 deaths. Legionella was associated with 57% of these outbreaks and all of the deaths. Sixty-nine percent of the reported illnesses occurred in four outbreaks in which the etiology was determined to be either a chemical or toxin or the parasite Cryptosporidium. Drinking water contamination events can cause disruptions in water service, large impacts on public health, and persistent community concern about drinking water quality. Effective water treatment and regulations can protect public drinking water supplies in the United States, and rapid detection, identification of the cause, and response to illness reports can reduce the transmission of infectious pathogens and harmful chemicals and toxins.}, journal={MMWR. Morbidity and mortality weekly report}, year={2017}, month={Nov} }
 @article{greenfield_moore_stewart_hilborn_george_li_dickerson_keppler_sandifer_2017, title={Temporal and Environmental Factors Driving Vibrio Vulnificus and V. Parahaemolyticus Populations and Their Associations With Harmful Algal Blooms in South Carolina Detention Ponds and Receiving Tidal Creeks}, url={https://doi.org/10.1002/2017GH000094}, DOI={10.1002/2017GH000094}, abstractNote={Abstract}, author={Greenfield, D. I. and Moore, J. Gooch and Stewart, J. R. and Hilborn, E. D. and George, B. J. and Li, Q. and Dickerson, J. and Keppler, C. K. and Sandifer, P. A.}, year={2017} }
 @article{waterborne disease outbreaks associated with environmental and undetermined exposures to water - united states, 2013-2014._2017, url={https://europepmc.org/articles/PMC5679586}, DOI={10.15585/mmwr.mm6644a4}, abstractNote={Waterborne disease outbreaks in the United States are associated with a wide variety of water exposures and are reported annually to CDC on a voluntary basis by state and territorial health departments through the National Outbreak Reporting System (NORS). A majority of outbreaks arise from exposure to drinking water (1) or recreational water (2), whereas others are caused by an environmental exposure to water or an undetermined exposure to water. During 2013-2014, 15 outbreaks associated with an environmental exposure to water and 12 outbreaks with an undetermined exposure to water were reported, resulting in at least 289 cases of illness, 108 hospitalizations, and 17 deaths. Legionella was responsible for 63% of the outbreaks, 94% of hospitalizations, and all deaths. Outbreaks were also caused by Cryptosporidium, Pseudomonas, and Giardia, including six outbreaks of giardiasis caused by ingestion of water from a river, stream, or spring. Water management programs can effectively prevent outbreaks caused by environmental exposure to water from human-made water systems, while proper point-of-use treatment of water can prevent outbreaks caused by ingestion of water from natural water systems.}, journal={MMWR. Morbidity and mortality weekly report}, year={2017}, month={Nov} }
 @article{loftin_graham_hilborn_lehmann_meyer_dietze_griffith_2016, title={Cyanotoxins in inland lakes of the United States: Occurrence and potential recreational health risks in the EPA National Lakes Assessment 2007}, url={http://dx.doi.org/10.1016/j.hal.2016.04.001}, DOI={10.1016/j.hal.2016.04.001}, abstractNote={A large nation-wide survey of cyanotoxins (1161 lakes) in the United States (U.S.) was conducted during the EPA National Lakes Assessment 2007. Cyanotoxin data were compared with cyanobacteria abundance- and chlorophyll-based World Health Organization (WHO) thresholds and mouse toxicity data to evaluate potential recreational risks. Cylindrospermopsins, microcystins, and saxitoxins were detected (ELISA) in 4.0, 32, and 7.7% of samples with mean concentrations of 0.56, 3.0, and 0.061 μg/L, respectively (detections only). Co-occurrence of the three cyanotoxin classes was rare (0.32%) when at least one toxin was detected. Cyanobacteria were present and dominant in 98 and 76% of samples, respectively. Potential anatoxin-, cylindrospermopsin-, microcystin-, and saxitoxin-producing cyanobacteria occurred in 81, 67, 95, and 79% of samples, respectively. Anatoxin-a and nodularin-R were detected (LC/MS/MS) in 15 and 3.7% samples (n = 27). The WHO moderate and high risk thresholds for microcystins, cyanobacteria abundance, and total chlorophyll were exceeded in 1.1, 27, and 44% of samples, respectively. Complete agreement by all three WHO microcystin metrics occurred in 27% of samples. This suggests that WHO microcystin metrics based on total chlorophyll and cyanobacterial abundance can overestimate microcystin risk when compared to WHO microcystin thresholds. The lack of parity among the WHO thresholds was expected since chlorophyll is common amongst all phytoplankton and not all cyanobacteria produce microcystins.}, author={Loftin, Keith A. and Graham, Jennifer L. and Hilborn, Elizabeth D. and Lehmann, Sarah C. and Meyer, Michael T. and Dietze, Julie E. and Griffith, Christopher B.}, year={2016} }
 @article{smith_ghio_stout_messier_hudgens_murphy_pfaller_maillard_hilborn_2016, title={Epidemiology of nontuberculous mycobacteria isolations among central North Carolina residents, 2006–2010}, url={http://dx.doi.org/10.1016/j.jinf.2016.03.008}, DOI={10.1016/j.jinf.2016.03.008}, abstractNote={Background Nontuberculous mycobacteria (NTM) are environmental mycobacteria associated with a range of infections. Reports of NTM epidemiology have primarily focused on pulmonary infections and isolations, however extrapulmonary infections of the skin, soft tissues and sterile sites are less frequently described. Methods We comprehensively reviewed laboratory reports of NTM isolation from North Carolina residents of three counties during 2006–2010. We describe age, gender, and race of patients, and anatomic site of isolation for NTM species. Results Among 1033 patients, overall NTM isolation prevalence was 15.9/100,000 persons (13.7/100,000 excluding Mycobacterium gordonae). Prevalence was similar between genders and increased significantly with age. Extrapulmonary isolations among middle-aged black males and pulmonary isolations among elderly white females were most frequently detected. Most isolations from pulmonary sites and blood cultures were Mycobacterium avium complex; rapidly growing NTM (e.g. Mycobacterium chelonae, Mycobacterium fortuitum) were most often isolated from paranasal sinuses, wounds and skin. Conclusions We provide the first characterization of NTM isolation prevalence in the Southeastern United States (U.S.). Variation in isolation prevalence among counties and races likely represent differences in detection, demographics and risk factors. Further characterization of NTM epidemiology is increasingly important as percentages of immunocompromised individuals and the elderly increase in the U.S. population.}, journal={The Journal of infection}, author={Smith, Genee S. and Ghio, Andrew J. and Stout, Jason E. and Messier, Kyle P. and Hudgens, Edward E. and Murphy, Mark S. and Pfaller, Stacy L. and Maillard, Jean-Marie and Hilborn, Elizabeth D.}, year={2016} }
 @article{crooks_cascio_percy_reyes_neas_hilborn_2016, title={The Association between Dust Storms and Daily Non-Accidental Mortality in the United States, 1993–2005}, url={https://doi.org/10.17615/7yw1-2f34}, DOI={10.17615/7yw1-2f34}, author={Crooks, James Lewis and Cascio, Wayne E. and Percy, Madelyn S. and Reyes, Jeanette and Neas, Lucas M. and Hilborn, Elizabeth D.}, year={2016} }
 @article{a prospective study of marine phytoplankton and reported illness among recreational beachgoers in puerto rico, 2009._2015, url={https://europepmc.org/articles/PMC4829982}, DOI={10.1289/ehp.1409558}, abstractNote={Background: Blooms of marine phytoplankton may adversely affect human health. The potential public health impact of low-level exposures is not well established, and few prospective cohort studies of recreational exposures to marine phytoplankton have been conducted. Objective: We evaluated the association between phytoplankton cell counts and subsequent illness among recreational beachgoers. Methods: We recruited beachgoers at Boquerón Beach, Puerto Rico, during the summer of 2009. We conducted interviews at three time points to assess baseline health, water activities, and subsequent illness. Daily water samples were quantitatively assayed for phytoplankton cell count. Logistic regression models, adjusted for age and sex, were used to assess the association between exposure to three categories of phytoplankton concentration and subsequent illness. Results: During 26 study days, 15,726 individuals successfully completed all three interviews. Daily total phytoplankton cell counts ranged from 346 to 2,012 cells/mL (median, 712 cells/mL). The category with the highest (≥ 75th percentile) total phytoplankton cell count was associated with eye irritation [adjusted odds ratio (OR) = 1.30; 95% confidence interval (CI): 1.01, 1.66], rash (OR = 1.27; 95% CI: 1.02, 1.57), and earache (OR = 1.25; 95% CI: 0.88, 1.77). In phytoplankton group-specific analyses, the category with the highest Cyanobacteria counts was associated with respiratory illness (OR = 1.37; 95% CI: 1.12, 1.67), rash (OR = 1.32; 95% CI: 1.05, 1.66), eye irritation (OR = 1.25; 95% CI: 0.97, 1.62), and earache (OR = 1.35; 95% CI: 0.95, 1.93). Conclusions: We found associations between recreational exposure to marine phytoplankton and reports of eye irritation, respiratory illness, and rash. We also found that associations varied by phytoplankton group, with Cyanobacteria having the strongest and most consistent associations. Citation: Lin CJ, Wade TJ, Sams EA, Dufour AP, Chapman AD, Hilborn ED. 2016. A prospective study of marine phytoplankton and reported illness among recreational beachgoers in Puerto Rico, 2009. Environ Health Perspect 124:477–483; http://dx.doi.org/10.1289/ehp.1409558}, journal={Environmental health perspectives}, year={2015}, month={Sep} }
 @article{environmental influences on the seasonal distribution of vibrio parahaemolyticus in the pacific northwest of the usa._2015, url={https://doi.org/10.1093/femsec/fiv121}, DOI={10.1093/femsec/fiv121}, abstractNote={Populations of Vibrio parahaemolyticus in the environment can be influenced by numerous factors. We assessed the correlation of total (tl+) and potentially virulent (tdh+) V. parahaemolyticus in water with three harmful algal bloom (HAB) genera (Pseudo-nitzschia, Alexandrium and Dinophysis), the abundance of diatoms and dinoflagellates, chlorophyll-a and temperature, salinity and macronutrients at five sites in Washington State from 2008-2009. The variability in V. parahaemolyticus density was explained predominantly by strong seasonal trends where maximum densities occurred in June, 2 months prior to the highest seasonal water temperature. In spite of large geographic differences in temperature, salinity and nutrients, there was little evidence of corresponding differences in V. parahaemolyticus density. In addition, there was no evident relationship between V. parahaemolyticus and indices of HAB genera, perhaps due to a lack of significant HAB events during the sampling period. The only nutrient significantly associated with V. parahaemolyticus density after accounting for the seasonal trend was silicate. This negative relationship may be caused by a shift in cell wall structure for some diatom species to a chitinous substrate preferred by V. parahaemolyticus. Results from our study differ from those in other regions corroborating previous findings that environmental factors that trigger vibrio and HAB events may differ depending on geographic locations. Therefore caution should be used when applying results from one region to another.}, journal={FEMS microbiology ecology}, year={2015}, month={Oct} }
 @article{krueger_hilborn_converse_wade_2015, title={Environmental risk factors associated with Helicobacter pylori seroprevalence in the United States: a cross-sectional analysis of NHANES data}, url={http://dx.doi.org/10.1017/s0950268814003938}, DOI={10.1017/s0950268814003938}, abstractNote={SUMMARY}, journal={Epidemiology and infection}, author={KRUEGER, W. S. and HILBORN, E. D. and CONVERSE, R. R. and WADE, T. J.}, year={2015} }
 @article{epidemiology and ecology of opportunistic premise plumbing pathogens: legionella pneumophila, mycobacterium avium, and pseudomonas aeruginosa._2015, url={https://europepmc.org/articles/PMC4529011}, DOI={10.1289/ehp.1408692}, abstractNote={Background Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa are opportunistic premise plumbing pathogens (OPPPs) that persist and grow in household plumbing, habitats they share with humans. Infections caused by these OPPPs involve individuals with preexisting risk factors and frequently require hospitalization. Objectives The objectives of this report are to alert professionals of the impact of OPPPs, the fact that 30% of the population may be exposed to OPPPs, and the need to develop means to reduce OPPP exposure. We herein present a review of the epidemiology and ecology of these three bacterial OPPPs, specifically to identify common and unique features. Methods A Water Research Foundation–sponsored workshop gathered experts from across the United States to review the characteristics of OPPPs, identify problems, and develop a list of research priorities to address critical knowledge gaps with respect to increasing OPPP-associated disease. Discussion OPPPs share the common characteristics of disinfectant resistance and growth in biofilms in water distribution systems or premise plumbing. Thus, they share a number of habitats with humans (e.g., showers) that can lead to exposure and infection. The frequency of OPPP-infected individuals is rising and will likely continue to rise as the number of at-risk individuals is increasing. Improved reporting of OPPP disease and increased understanding of the genetic, physiologic, and structural characteristics governing the persistence and growth of OPPPs in drinking water distribution systems and premise plumbing is needed. Conclusions Because broadly effective community-level engineering interventions for the control of OPPPs have yet to be identified, and because the number of at-risk individuals will continue to rise, it is likely that OPPP-related infections will continue to increase. However, it is possible that individuals can take measures (e.g., raise hot water heater temperatures and filter water) to reduce home exposures. Citation Falkinham JO III, Hilborn ED, Arduino MJ, Pruden A, Edwards MA. 2015. Epidemiology and ecology of opportunistic premise plumbing pathogens: Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa. Environ Health Perspect 123:749–758; http://dx.doi.org/10.1289/ehp.1408692}, journal={Environmental health perspectives}, year={2015}, month={Mar} }
 @article{extreme precipitation and emergency room visits for gastrointestinal illness in areas with and without combined sewer systems: an analysis of massachusetts data, 2003-2007._2015, url={https://europepmc.org/articles/PMC4559956}, DOI={10.1289/ehp.1408971}, abstractNote={Background Combined sewer overflows (CSOs) occur in combined sewer systems when sewage and stormwater runoff are released into water bodies, potentially contaminating water sources. CSOs are often caused by heavy precipitation and are expected to increase with increasing extreme precipitation associated with climate change. Objectives The aim of this study was to assess whether the association between heavy rainfall and rate of emergency room (ER) visits for gastrointestinal (GI) illness differed in the presence of CSOs. Methods For the study period 2003–2007, time series of daily rate of ER visits for GI illness and meteorological data were organized for three exposure regions: a) CSOs impacting drinking water sources, b) CSOs impacting recreational waters, c) no CSOs. A distributed lag Poisson regression assessed cumulative effects for an 8-day lag period following heavy (≥ 90th and ≥ 95th percentile) and extreme (≥ 99th percentile) precipitation events, controlling for temperature and long-term time trends. Results The association between extreme rainfall and rate of ER visits for GI illness differed among regions. Only the region with drinking water exposed to CSOs demonstrated a significant increased cumulative risk for rate (CRR) of ER visits for GI for all ages in the 8-day period following extreme rainfall: CRR: 1.13 (95% CI: 1.00, 1.28) compared with no rainfall. Conclusions The rate of ER visits for GI illness was associated with extreme precipitation in the area with CSO discharges to a drinking water source. Our findings suggest an increased risk for GI illness among consumers whose drinking water source may be impacted by CSOs after extreme precipitation. Citation Jagai JS, Li Q, Wang S, Messier KP, Wade TJ, Hilborn ED. 2015. Extreme precipitation and emergency room visits for gastrointestinal illness in areas with and without combined sewer systems: an analysis of Massachusetts data, 2003–2007. Environ Health Perspect 123:873–879; http://dx.doi.org/10.1289/ehp.1408971}, journal={Environmental health perspectives}, year={2015}, month={Apr} }
 @article{lin_wade_hilborn_2015, title={Flooding and Clostridium difficile Infection: A Case-Crossover Analysis}, url={https://doi.org/10.3390/ijerph120606948}, DOI={10.3390/ijerph120606948}, abstractNote={Clostridium difficile is a bacterium that can spread by water. It often causes acute gastrointestinal illness in older adults who are hospitalized and/or receiving antibiotics; however, community-associated infections affecting otherwise healthy individuals have become more commonly reported. A case-crossover study was used to assess emergency room (ER) and outpatient visits for C. difficile infection following flood events in Massachusetts from 2003 through 2007. Exposure status was based on whether or not a flood occurred prior to the case/control date during the following risk periods: 0–6 days, 7–13 days, 14–20 days, and 21–27 days. Fixed-effects logistic regression was used to estimate the risk of diagnosis with C. difficile infection following a flood. There were 129 flood events and 1575 diagnoses of C. difficile infection. Among working age adults (19–64 years), ER and outpatient visits for C. difficile infection were elevated during the 7–13 days following a flood (Odds Ratio, OR = 1.69; 95% Confidence Interval, CI: 0.84, 3.37). This association was more substantial among males (OR = 3.21; 95% CI: 1.01–10.19). Associations during other risk periods were not observed (p < 0.05). Although we were unable to differentiate community-associated versus nosocomial infections, a potential increase in C. difficile infections should be considered as more flooding is projected due to climate change.}, journal={International journal of environmental research and public health}, author={Lin, Cynthia J. and Wade, Timothy J. and Hilborn, Elizabeth D.}, year={2015} }
 @article{messier_jackson_white_hilborn_2015, title={Landscape risk factors for Lyme disease in the eastern broadleaf forest province of the Hudson River valley and the effect of explanatory data classification resolution}, url={http://dx.doi.org/10.1016/j.sste.2014.10.002}, DOI={10.1016/j.sste.2014.10.002}, abstractNote={This study assessed how landcover classification affects associations between landscape characteristics and Lyme disease rate. Landscape variables were derived from the National Land Cover Database (NLCD), including native classes (e.g., deciduous forest, developed low intensity) and aggregate classes (e.g., forest, developed). Percent of each landcover type, median income, and centroid coordinates were calculated by census tract. Regression results from individual and aggregate variable models were compared with the dispersion parameter-based R(2) (Rα(2)) and AIC. The maximum Rα(2) was 0.82 and 0.83 for the best aggregate and individual model, respectively. The AICs for the best models differed by less than 0.5%. The aggregate model variables included forest, developed, agriculture, agriculture-squared, y-coordinate, y-coordinate-squared, income and income-squared. The individual model variables included deciduous forest, deciduous forest-squared, developed low intensity, pasture, y-coordinate, y-coordinate-squared, income, and income-squared. Results indicate that regional landscape models for Lyme disease rate are robust to NLCD landcover classification resolution.}, author={Messier, Kyle P. and Jackson, Laura E. and White, Jennifer L. and Hilborn, Elizabeth D.}, year={2015} }
 @article{hilborn_beasley_2015, title={One Health and Cyanobacteria in Freshwater Systems: Animal Illnesses and Deaths Are Sentinel Events for Human Health Risks}, url={https://doi.org/10.3390/toxins7041374}, DOI={10.3390/toxins7041374}, abstractNote={Harmful cyanobacterial blooms have adversely impacted human and animal health for thousands of years. Recently, the health impacts of harmful cyanobacteria blooms are becoming more frequently detected and reported. However, reports of human and animal illnesses or deaths associated with harmful cyanobacteria blooms tend to be investigated and reported separately. Consequently, professionals working in human or in animal health do not always communicate findings related to these events with one another. Using the One Health concept of integration and collaboration among health disciplines, we systematically review the existing literature to discover where harmful cyanobacteria-associated animal illnesses and deaths have served as sentinel events to warn of potential human health risks. We find that illnesses or deaths among livestock, dogs and fish are all potentially useful as sentinel events for the presence of harmful cyanobacteria that may impact human health. We also describe ways to enhance the value of reports of cyanobacteria-associated illnesses and deaths in animals to protect human health. Efficient monitoring of environmental and animal health in a One Health collaborative framework can provide vital warnings of cyanobacteria-associated human health risks.}, author={Hilborn, Elizabeth D. and Beasley, Val R.}, year={2015} }
 @article{outbreaks associated with environmental and undetermined water exposures - united states, 2011-2012._2015, url={https://europepmc.org/articles/PMC4584590}, DOI={10.15585/mmwr.mm6431a3}, abstractNote={Exposures to contaminated water can lead to waterborne disease outbreaks associated with various sources, including many that are classified and reported separately as drinking water or recreational water. Waterborne disease outbreaks can also involve a variety of other exposures (e.g., consuming water directly from backcountry or wilderness streams, or inhaling aerosols from cooling towers and ornamental fountains). Additionally, outbreaks might be epidemiologically linked to multiple water sources or may not have a specific water source implicated.}, journal={MMWR. Morbidity and mortality weekly report}, year={2015}, month={Aug} }
 @article{outbreaks of illness associated with recreational water--united states, 2011-2012._2015, url={https://europepmc.org/articles/PMC4584744}, journal={MMWR. Morbidity and mortality weekly report}, year={2015}, month={Jun} }
 @article{krueger_hilborn_dufour_sams_wade_2015, title={Self-Reported Acute Health Effects and Exposure to Companion Animals}, url={http://dx.doi.org/10.1111/zph.12233}, DOI={10.1111/zph.12233}, abstractNote={Summary}, journal={Zoonoses and public health}, author={Krueger, W. S. and Hilborn, E. D. and Dufour, A. P. and Sams, E. A. and Wade, T. J.}, year={2015} }
 @article{surveillance for waterborne disease outbreaks associated with drinking water - united states, 2011-2012._2015, url={https://europepmc.org/articles/PMC4584589}, DOI={10.15585/mmwr.mm6431a2}, abstractNote={Advances in water management and sanitation have substantially reduced waterborne disease in the United States, although outbreaks continue to occur. Public health agencies in the U.S. states and territories* report information on waterborne disease outbreaks to the CDC Waterborne Disease and Outbreak Surveillance System (http://www.cdc.gov/healthywater/surveillance/index.html). For 2011-2012, 32 drinking water-associated outbreaks were reported, accounting for at least 431 cases of illness, 102 hospitalizations, and 14 deaths. Legionella was responsible for 66% of outbreaks and 26% of illnesses, and viruses and non-Legionella bacteria together accounted for 16% of outbreaks and 53% of illnesses. The two most commonly identified deficiencies† leading to drinking water-associated outbreaks were Legionella in building plumbing§ systems (66%) and untreated groundwater (13%). Continued vigilance by public health, regulatory, and industry professionals to identify and correct deficiencies associated with building plumbing systems and groundwater systems could prevent most reported outbreaks and illnesses associated with drinking water systems.}, journal={MMWR. Morbidity and mortality weekly report}, year={2015}, month={Aug} }
 @article{the risk of cyanobacterial toxins in dialysate: what do we know?_2015, url={https://doi.org/10.1111/sdi.12420}, DOI={10.1111/sdi.12420}, abstractNote={Abstract}, journal={Seminars in dialysis}, year={2015}, month={Aug} }
 @article{algal bloom-associated disease outbreaks among users of freshwater lakes--united states, 2009-2010._2014, url={https://europepmc.org/articles/PMC5779332}, journal={MMWR. Morbidity and mortality weekly report}, year={2014}, month={Jan} }
 @article{drinking water source and human toxoplasma gondii infection in the united states: a cross-sectional analysis of nhanes data._2014, url={https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/25012250/?tool=EBI}, DOI={10.1186/1471-2458-14-711}, abstractNote={Toxoplasma gondii imparts a considerable burden to public health. Human toxoplasmosis can be life-threatening in immunocompromised individuals, has been associated with psychiatric disorders, and can cause severe congenital pathologies, spontaneous abortion, or stillbirth. Environmental modes of transmission contributing to the incidence of human toxoplasmosis are poorly understood. We sought to examine National Health and Nutrition Examination Survey (NHANES) data for risk factors associated with T. gondii seroprevalence.T. gondii serology results reported for Continuous NHANES survey years 1999-2004 and 2009-10 were examined. To explore associations with toxoplasmosis seropositivity, covariates of interest were selected a priori, including source and home treatment of tap water. Associations between potential risk factors and evidence of IgG antibodies against T. gondii were assessed using multivariable logistic regression.Among 23,030 participants with available T. gondii serology across 8 years of continuous NHANES survey data (1999-2004; 2009-2010), persons born outside the United States were significantly more likely to be seropositive, and seropositivity was inversely associated with years spent in the United States. Among US-born participants, participants with homes on well water (both those who used at-home water treatment devices and those who did not), as well as participants with public/private company-provided tap water who did not use at-home water treatment devices, were significantly more likely to be seropositive compared to participants who used home treatment devices on tap water provided by a private or public water company. A comparative subpopulation analysis revealed age-adjusted seroprevalence among US-born persons 12-49 yrs old significantly declined to 6.6% (95% CI, 5.2-8.0) (P <0.0001) in 2009-10, compared to previously published reports for NHANES data from 1988-1994 (14.1%) and 1999-2004 (9.0%).Data suggests that T. gondii infections continue to decline in the United States, but the overall infection rate remains substantial at nearly 7%. Despite the limitations in the Continuous NHANES cross-sectional survey, the association between well water use and T. gondii infection warrants further research.}, journal={BMC public health}, year={2014}, month={Jul} }
 @article{effect of microcystin-lr on human placental villous trophoblast differentiation in vitro._2014, url={https://doi.org/10.1002/tox.22056}, DOI={10.1002/tox.22056}, abstractNote={Microcystin‐LR is a cyanobacterial toxin found in surface and recreational waters that inhibits protein phosphatases and may disrupt the cytoskeleton. Microcystins induce apoptosis in hepatocytes at ≤2.0 µM. Nothing is known about the effects of microcystins on human placental trophoblast differentiation and function. The differentiation of villous trophoblasts to form syncytiotrophoblast occurs throughout pregnancy and is essential for normal placental and fetal development. To investigate the effects of microcystin, villous cytotrophoblasts were isolated from term placentas using an established method and exposed to microcystin‐LR. Microcystin‐LR below the cytotoxic dose of 25 µM did not cause cell rounding or detachment, had no effect on apoptosis, and no effect on the morphological differentiation of mononucleated cytotrophoblasts to multinucleated syncytiotrophoblast. However, secretion of human chorionic gonadotropin (hCG) increased in a microcystin‐LR dose‐dependent manner. When incubated with l‐buthionine sulphoximine (BSO) to deplete glutathione levels, trophoblast morphological differentiation proceeded normally in the presence of microcystin‐LR. Microcystin‐LR did not disrupt the trophoblast microtubule cytoskeleton, which is known to play a role in trophoblast differentiation. Immunofluorescence studies showed that trophoblasts express organic anion transport protein 1B3 (OATP1B3), a known microcystin transport protein. In comparison to hepatocytes, trophoblasts appear to be more resistant to the toxic effects of microcystin‐LR. The physiological implications of increased hCG secretion in response to microcystin‐LR exposure remain to be determined. © 2014 Wiley Periodicals, Inc. Environ Toxicol 31: 427–439, 2016.}, journal={Environmental toxicology}, year={2014}, month={Oct} }
 @article{wade_lin_jagai_hilborn_2014, title={Flooding and emergency room visits for gastrointestinal illness in Massachusetts: a case-crossover study.}, url={https://doi.org/10.1371/journal.pone.0110474}, DOI={10.1371/journal.pone.0110474}, abstractNote={Introduction Floods and other severe weather events are anticipated to increase as a result of global climate change. Floods can lead to outbreaks of gastroenteritis and other infectious diseases due to disruption of sewage and water infrastructure and impacts on sanitation and hygiene. Floods have also been indirectly associated with outbreaks through population displacement and crowding. Methods We conducted a case-crossover study to investigate the association between flooding and emergency room visits for gastrointestinal illness (ER-GI) in Massachusetts for the years 2003 through 2007. We obtained ER-GI visits from the State of Massachusetts and records of floods from the National Oceanic and Atmospheric Association’s Storm Events Database. ER-GI visits were considered exposed if a flood occurred in the town of residence within three hazard periods of the visit: 0–4 days; 5–9 days; and 10–14 days. A time-stratified bi-directional design was used for control selection, matching on day of the week with two weeks lead or lag time from the ER-GI visit. Fixed effect logistic regression models were used to estimate the risk of ER-GI visits following the flood. Results and Conclusions A total of 270,457 ER-GI visits and 129 floods occurred in Massachusetts over the study period. Across all counties, flooding was associated with an increased risk for ER-GI in the 0–4 day period after flooding (Odds Ratio: 1.08; 95% Confidence Interval: 1.03–1.12); but not the 5–9 days (Odds Ratio: 0.995; 95% Confidence Interval: 0.955–1.04) or the 10–14 days after (Odds Ratio: 0.966, 95% Confidence Interval: 0.927–1.01). Similar results were observed for different definitions of ER-GI. The effect differed across counties, suggesting local differences in the risk and impact of flooding. Statewide, across the study period, an estimated 7% of ER-GI visits in the 0–4 days after a flood event were attributable to flooding.}, journal={PloS one}, author={Wade, Timothy J and Lin, Cynthia J and Jagai, Jyotsna S and Hilborn, Elizabeth D}, year={2014} }
 @article{recreational water-associated disease outbreaks--united states, 2009-2010._2014, url={https://europepmc.org/articles/PMC5779330}, journal={MMWR. Morbidity and mortality weekly report}, year={2014}, month={Jan} }
 @article{shared mycobacterium avium genotypes observed among unlinked clinical and environmental isolates._2013, url={https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/23851084/?tool=EBI}, DOI={10.1128/aem.01443-13}, abstractNote={ABSTRACT}, journal={Applied and environmental microbiology}, year={2013}, month={Jul} }
 @book{state of the science and research needs for opportunistic pathogens in premise plumbing_2013, url={https://www.waterrf.org/research/projects/state-science-and-research-needs-opportunistic-pathogens-premise-plumbing}, year={2013} }
 @article{hilborn_soares_servaites_delgado_magalhães_carmichael_azevedo_2013, title={Sublethal microcystin exposure and biochemical outcomes among hemodialysis patients.}, url={https://doi.org/10.1371/journal.pone.0069518}, DOI={10.1371/journal.pone.0069518}, abstractNote={Cyanobacteria are commonly-occurring contaminants of surface waters worldwide. Microcystins, potent hepatotoxins, are among the best characterized cyanotoxins. During November, 2001, a group of 44 hemodialysis patients were exposed to microcystins via contaminated dialysate. Serum microcystin concentrations were quantified with enzyme-linked immunosorbent assay which measures free serum microcystin LR equivalents (ME). We describe serum ME concentrations and biochemical outcomes among a subset of patients during 8 weeks following exposure. Thirteen patients were included; 6 were males, patients’ median age was 45 years (range 16–80), one was seropositive for hepatitis B surface antigen. The median serum ME concentration was 0.33 ng/mL (range: <0.16–0.96). One hundred thirty nine blood samples were collected following exposure. Patients’ biochemical outcomes varied, but overall indicated a mixed liver injury. Linear regression evaluated each patient’s weekly mean biochemical outcome with their maximum serum ME concentration; a measure of the extrinsic pathway of clotting function, prothrombin time, was negatively and significantly associated with serum ME concentrations. This group of exposed patients’ biochemical outcomes display evidence of a mixed liver injury temporally associated with microcystin exposure. Interpretation of biochemical outcomes are complicated by the study population’s underlying chronic disease status. It is clear that dialysis patients are a distinct ‘at risk’ group for cyanotoxin exposures due to direct intravenous exposure to dialysate prepared from surface drinking water supplies. Careful monitoring and treatment of water supplies used to prepare dialysate is required to prevent future cyanotoxin exposure events.}, journal={PloS one}, author={Hilborn, Elizabeth D and Soares, Raquel M and Servaites, Jerome C and Delgado, Alvima G and Magalhães, Valéria F and Carmichael, Wayne W and Azevedo, Sandra M F O}, year={2013} }
 @article{surveillance for waterborne disease outbreaks associated with drinking water and other nonrecreational water - united states, 2009-2010._2013, url={https://europepmc.org/articles/PMC4585624}, journal={MMWR. Morbidity and mortality weekly report}, year={2013}, month={Sep} }
 @article{hilborn_catanzaro_jackson_2012, title={Repeated holdout cross-validation of model to estimate risk of Lyme disease by landscape characteristics}, url={http://dx.doi.org/10.1080/09603123.2011.588320}, DOI={10.1080/09603123.2011.588320}, abstractNote={We previously modeled Lyme disease (LD) risk at the landscape scale; here we evaluate the model's overall goodness-of-fit using holdout validation. Landscapes were characterized within road-bounded analysis units (AU). Observed LD cases (obsLD) were ascertained per AU. Data were randomly subset 2,000 times. Of 514 AU, 411 (80%) were selected as a training dataset to develop parameter estimates used to predict observations in the remaining 103 (20%) AU, the validation subset. Predicted values were subtracted from obsLD to quantify accuracy across iterations. We calculated the percentage difference of over- and under-estimation to assess bias. Predictive ability was strong and similar across iterations and datasets; the exact number of obsLD cases per AU were predicted almost 60% of the time. However, the three highest obsLD AU were under-predicted. Our model appears to be accurate and relatively unbiased, however is conservative at high disease incidence.}, author={Hilborn, Elizabeth D. and Catanzaro, Donald G. and Jackson, Laura E.}, year={2012} }
 @article{surveillance for waterborne disease outbreaks and other health events associated with recreational water --- united states, 2007--2008._2011, journal={Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C. : 2002)}, year={2011}, month={Sep} }
 @article{surveillance for waterborne disease outbreaks associated with drinking water---united states, 2007--2008._2011, journal={Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C. : 2002)}, year={2011}, month={Sep} }
 @inbook{environment and lyme disease risk_2010, url={http://www.novapublishers.org/catalog/product_info.php?products_id=19167}, booktitle={Handbook of Disease Outbreaks: Prevention, Detection and Control}, year={2010} }
 @article{structural analysis of biofilm formation by rapidly and slowly growing nontuberculous mycobacteria._2009, url={https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/19201956/?tool=EBI}, DOI={10.1128/aem.00166-09}, abstractNote={ABSTRACT}, journal={Applied and environmental microbiology}, year={2009}, month={Feb} }
 @article{ecosystem effects workgroup report._2008, url={https://doi.org/10.1007/978-0-387-75865-7_31}, DOI={10.1007/978-0-387-75865-7_31}, journal={Advances in experimental medicine and biology}, year={2008}, month={Jan} }
 @article{human health effects workgroup report._2008, url={https://doi.org/10.1007/978-0-387-75865-7_26}, DOI={10.1007/978-0-387-75865-7_26}, journal={Advances in experimental medicine and biology}, year={2008}, month={Jan} }
 @article{molecular comparison of mycobacterium avium isolates from clinical and environmental sources._2008, url={https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/18539815/?tool=EBI}, DOI={10.1128/aem.02900-07}, abstractNote={ABSTRACT}, journal={Applied and environmental microbiology}, year={2008}, month={Jun} }
 @article{particulate matter in cigarette smoke alters iron homeostasis to produce a biological effect._2008, url={https://doi.org/10.1164/rccm.200802-334OC}, DOI={10.1164/rccm.200802-334oc}, abstractNote={RATIONALE
Lung injury after cigarette smoking is related to particle retention. Iron accumulates with the deposition of these particles.


OBJECTIVES
We tested the postulate that (1) injury after smoking correlates with exposure to the particulate fraction of cigarette smoke, (2) these particles alter iron homeostasis, triggering metal accumulation, and (3) this alteration in iron homeostasis affects oxidative stress and inflammation.


METHODS
Rats and human respiratory epithelial cells were exposed to cigarette smoke, filtered cigarette smoke, and cigarette smoke condensate (the particulate fraction of smoke), and indices of iron homeostasis, oxidative stress, and inflammatory injury were determined. Comparable measures were also evaluated in nonsmokers and smokers.


MEASUREMENTS AND MAIN RESULTS
After exposure of rats to cigarette smoke, increased lavage concentrations of iron and ferritin, serum ferritin levels, and nonheme iron concentrations in the lung and liver tissue all increased. Lavage ascorbate concentrations were decreased, supporting an oxidative stress. After filtering of the cigarette smoke to remove particles, most of these changes were reversed. Exposure of cultured respiratory epithelial cells to cigarette smoke condensate caused a similar accumulation of iron, metal-dependent oxidative stress, and increased IL-8 release. Lavage samples in healthy smokers and smoking patients with chronic obstructive pulmonary disease revealed elevated concentrations of both iron and ferritin relative to healthy nonsmokers. Lavage ascorbate decreased with cigarette smoking. Serum iron and ferritin levels among smokers were increased, supporting systemic accumulation of this metal after cigarette smoke exposure.


CONCLUSIONS
We conclude that cigarette smoke particles alter iron homeostasis, both in the lung and systemically.}, journal={American journal of respiratory and critical care medicine}, year={2008}, month={Aug} }
 @article{hilborn_carmichael_soares_yuan_servaites_barton_azevedo_2007, title={Serologic evaluation of human microcystin exposure}, url={http://dx.doi.org/10.1002/tox.20281}, DOI={10.1002/tox.20281}, abstractNote={Abstract}, journal={Environmental toxicology}, author={Hilborn, E. D. and Carmichael, W. W. and Soares, R. M. and Yuan, M. and Servaites, J. C. and Barton, H. A. and Azevedo, S. M. F. O.}, year={2007} }
 @article{jackson_levine_hilborn_2006, title={A comparison of analysis units for associating Lyme disease with forest-edge habitat}, volume={7}, ISSN={["1588-2756"]}, url={http://dx.doi.org/10.1556/comec.7.2006.2.6}, DOI={10.1556/comec.7.2006.2.6}, abstractNote={The rational definition of spatial analysis units is critical to modeling and understanding large-scale ecological processes. This study assessed the relationship between forest-edge habitat pattern and Lyme disease incidence rate when modeled under three designs for spatial data aggregation. Incidence rates were calculated from passive surveillance data reported for 12 counties in the U.S. State of Maryland during 1996–2000. A design using road-bounded polygons that varied in size from 0.002 km 2 to 368 km 2 ( n = 415) was compared with designs that used grid cells of 10 km 2 ( n = 823) and 36 km 2 ( n = 230). Major roads were chosen to approximate bounded populations of deer and humans engaged in outdoor activity around the home (peridomestic activity). While cell boundaries were arbitrary, cell sizes were chosen to eliminate outliers observed in small polygons, and to standardize the presumed zone of exposure. The single variable that explained the most variation in incidence rate across all study desi...}, number={2}, journal={COMMUNITY ECOLOGY}, author={Jackson, L. E. and Levine, J. F. and Hilborn, E. D.}, year={2006}, pages={189–197} }
 @article{microcystin analysis in human sera and liver from human fatalities in caruaru, brazil 1996._2006, url={https://doi.org/10.1016/j.toxicon.2006.07.031}, DOI={10.1016/j.toxicon.2006.07.031}, abstractNote={In 1996, an extensive exposure of Brazilian hemodialysis patients at a dialysis center, using a municipal water supply water contaminated with cyanotoxins, provided the first evidence for acute lethal human poisoning from the cyclic peptide hepatotoxins called microcystins. During this outbreak, 100 of 131 patients developed acute liver failure and 52 of these victims were confirmed to have been exposed to lethal levels of microcystins. Detection and quantitation of microcystins in these biological samples posed some analytical challenges since there were no well-established and routine analytic methods to measure total microcystins in tissue or sera samples. At the time of the 1996 exposure we used analytic methods that combined the use of enzyme linked immunosorbant assay (ELISA), analytical high performance liquid chromatography (HPLC), electrospray ionization ion-trap mass spectroscopy (ES-ITMS) and matrix assisted laser desorption ionization-time of flight spectroscopy (MALDI-TOF). In the intervening years these methods have been improved and others developed that allow a more quantitative and critical analysis of microcystin contaminated tissue and sera. For these reasons, and to see how storage with time might effect the detection and stability of microcystins in these matrices, we reanalyzed selected liver tissues and sera from the Caruaru victims in Brazil. We developed and validated a procedure to measure total microcystins in Caruaru human sera and liver tissue using a combination of ELISA, liquid chromatography and liquid chromatography–mass spectrometry (LC/MS), GC/MS and MS/MS techniques. GC/MS and LC/MS were followed by MS/MS to obtain a fingerprint fragment spectra for the microcystins. The validity of the extraction procedure for free microcystins was confirmed by recovery experiments with blood sera spiked with microcystin-LR. We removed proteins with the Microcon® Centrifugal Filter prior to LC/MS and ELISA analysis. A solid phase extraction (SPE) procedure was used for analysis of protein bound microcystins by conversion of ADDA to erythro-2-methyl-3-methoxy-4-phenylbutyric acid (MMPB) combined with GC/MS. We found that the GC/MS method yielded a higher concentration of microcystin than that obtained by ELISA and LC/MS. We hypothesize that this difference is due to better GC/MS detection of the covalently bound form of microcystins in human liver tissue. We also concluded that microcystins are very stable when stored under these conditions for periods of almost 10 years.}, journal={Toxicon : official journal of the International Society on Toxinology}, year={2006}, month={Jul} }
 @article{persistence of nontuberculous mycobacteria in a drinking water system after addition of filtration treatment._2006, url={https://europepmc.org/articles/PMC1563680}, DOI={10.1128/aem.00759-06}, abstractNote={ABSTRACT}, journal={Applied and environmental microbiology}, year={2006}, month={Sep} }
 @article{sublethal exposure from microcystins to renal insufficiency patients in rio de janeiro, brazil._2006, url={https://doi.org/10.1002/tox.20160}, DOI={10.1002/tox.20160}, abstractNote={Abstract}, journal={Environmental toxicology}, year={2006}, month={Apr} }
 @article{jackson_hilborn_thomas_2006, title={Towards landscape design guidelines for reducing Lyme disease risk}, url={http://dx.doi.org/10.1093/ije/dyi284}, DOI={10.1093/ije/dyi284}, abstractNote={BACKGROUND
Incidence of Lyme disease in the US continues to grow. Low-density development is also increasing in endemic regions, raising questions about the relationship between development pattern and disease. This study sought to model Lyme disease incidence rate using quantitative, practical metrics of regional landscape pattern. The objective was to progress towards the development of design guidelines that may help minimize known threats to human and environmental health.


METHODS
Ecological analysis was used to accommodate the integral landscape variables under study. Case data derived from passive surveillance reports across 12 counties in the US state of Maryland during 1996-2000; 2,137 cases were spatially referenced to residential addresses. Major roads were used to delineate 514 landscape analysis units from 0.002 to 580 km(2).


RESULTS
The parameter that explained the most variation in incidence rate was the percentage of land-cover edge represented by the adjacency of forest and herbaceous cover [R(2) = 0.75; rate ratio = 1.34 (1.26-1.43); P < 0.0001]. Also highly significant was the percentage of the landscape in forest cover (cumulative R(2) = 0.82), which exhibited a quadratic relationship with incidence rate. Modelled relationships applied throughout the range of landscape sizes.


CONCLUSIONS
Results begin to provide quantitative landscape design parameters for reducing casual peridomestic contact with tick and host habitat. The final model suggests that clustered forest and herbaceous cover, as opposed to high forest-herbaceous interspersion, would minimize Lyme disease risk in low-density residential areas. Higher-density development that precludes a large percentage of forest-herbaceous edge would also limit exposure.}, journal={International journal of epidemiology}, author={Jackson, Laura E and Hilborn, Elizabeth D and Thomas, James C}, year={2006} }
 @article{a simple colorimetric method to detect biological evidence of human exposure to microcystins._2005, url={https://doi.org/10.1016/j.toxicon.2005.04.009}, DOI={10.1016/j.toxicon.2005.04.009}, abstractNote={Toxic cyanobacteria are contaminants of surface waters worldwide. Microcystins are some of the most commonly detected cyanotoxins. Biological evidence of human exposure may be difficult to obtain due to limitations associated with cost, laboratory capacity, analytic support, and expertise. We investigated the application of an enzyme-linked immunosorbant assay (ELISA) to detect microcystins in human serum. We analyzed ten serum samples collected from dialysis patients who were known to be exposed to a mixture of microcystins during a 1996 outbreak in Brazil. We applied a commercially available ELISA method to detect microcystins in serum, and we compared the ELISA results to a more specific method, liquid chromatography/mass spectrometry (LC/MS) that was also used to detect microcystins in serum. The Spearman correlation coefficient was calculated using serum microcystin concentrations in split samples obtained by the two methods. Serum microcystin concentrations were similar, and we found good correlation of microcystin concentrations between the two methods. The ELISA detected total microcystins, median=19.9 ng/ml; LC/MS detected microcystin-LR equivalents, median=21.2 ng/ml; Spearman r=0.96, p<0.0001. We found that ELISA is a simple, accessible method to screen human serum for evidence of microcystin exposure.}, journal={Toxicon : official journal of the International Society on Toxinology}, year={2005}, month={Aug} }
 @article{a dried blood spot method to evaluate cholinesterase activity in young children._2004, url={https://doi.org/10.1080/00039890409603427}, DOI={10.1080/00039890409603427}, abstractNote={Abstract Field methods are needed to detect and monitor the organophosphate pesticide exposure of young children. Twenty children, aged 11 to 18 mo, living in an agricultural community along the United States/Mexico border were enrolled in a pilot study investigating methods to detect pesticide exposure. Healthy children were recruited at pediatric clinics with the informed consent of their parents. Venous blood samples were collected from children twice, 4 wk apart. Cholinesterase activity was compared in whole heparinized venous blood with venous blood samples dried on filter paper. Although the amount of activity in the dried blood was consistently less than in the heparinized blood, the activity was significantly correlated: Spearman r = .6 (p = 0.01). This dried blood method may be used during field studies to evaluate changes in cholinesterase values in children over time.}, journal={Archives of environmental health}, year={2004}, month={Sep} }
 @article{hilborn_walsh_mendola_royster_2003, title={Methods for Conducting a Field Study of Young Children}, volume={1}, url={http://dx.doi.org/10.3109/713926153}, DOI={10.3109/713926153}, abstractNote={Concern about children's environmental health is increasing as newly characterized risks are identified. Often little data is available to guide policy decisions. Research on ambient exposures to environmental contaminants is essential to understand the magnitude and nature of risks to children's environmental health. However, the study of very young children is difficult due to logistical and societal limitations. The most successful field studies include recognition and accommodation of the study family's needs and the child's age and developmental-stage-specific characteristics. We will discuss specific elements to consider when designing and implementing field studies of pre-school children: site selection; development of the study plan and study team; screening and recruitment; informed consent; study implementation; data and sample collection; quality assurance/quality control; and study family communication.}, number={4}, journal={Journal of Children's Health}, publisher={Informa UK Limited}, author={Hilborn, Elizabeth and Walsh, Debra and Mendola, Pauline and Royster, Michael}, year={2003}, month={Jan}, pages={499–511} }
 @article{a pilot study of global positioning system/geographical information system measurement of residential proximity to agricultural fields and urinary organophosphate metabolite concentrations in toddlers._2002, url={https://doi.org/10.1038/sj.jea.7500247}, DOI={10.1038/sj.jea.7500247}, abstractNote={This pilot study enrolled 20 children between the ages of 11 and 17 months in Imperial County, California to assess children's pesticide exposure and residential proximity to agricultural fields. We compared parental self-report of residential proximity to agricultural fields to measurements using global positioning system/geographical information system (GPS/GIS) technology, and we assessed the relationship between residential proximity to agricultural fields and a biomarker of organophosphate (OP) pesticide exposure. Questionnaires were administered twice, 4 weeks apart, to determine self-reported residential proximity to agricultural fields. Urine samples were collected at each contact to measure OP metabolites. Actual residential proximity to the closest agricultural field and number of fields was within 1 mile to the west were measured using GPS/GIS. Self-report of living proximity to agricultural fields agreed with GPS/GIS measurement 75% of the time during the initial interview, compared to 66% agreement during the second interview. Presence of urinary metabolites suggests that OP exposure was ubiquitous: creatinine-adjusted total urinary dimethyl values ranged from 1.60 to 516.00 microg/g creatinine, and total diethyl ranged from 2.70 to 134.84 microg/g creatinine. No association was found between urinary OP metabolites and residential to field proximity. These results suggest that initial self-report of living proximity to agricultural fields may be more accurate than follow-up self-report. Limitations in this pilot study prevent determination of whether self-report is an accurate measure of proximity.}, journal={Journal of exposure analysis and environmental epidemiology}, year={2002}, month={Nov} }
 @article{phthalate monoesters levels in the urine of young children._2002, url={https://doi.org/10.1007/s001280255}, DOI={10.1007/s001280255}, journal={Bulletin of environmental contamination and toxicology}, year={2002}, month={Mar} }
 @article{hilborn_royster_drabkowski_2002, title={Survey of U.S. Public Health Laboratories: Microbial Pathogens of the Contaminant Candidate List}, volume={94}, url={http://www.jstor.org/stable/41298366}, number={6}, journal={Journal of the American Water Works Association}, author={Hilborn, E.D. and Royster, M.O. and Drabkowski, D.J.}, year={2002}, month={Jun}, pages={88–96} }
 @article{improving waterborne disease outbreak investigations._2001, url={https://doi.org/10.1080/09603120120070847}, DOI={10.1080/09603120120070847}, abstractNote={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.}, journal={International journal of environmental health research}, year={2001}, month={Sep} }
 @article{hilborn_mshar_fiorentino_dembek_barrett_howard_cartter_2000, title={An outbreak of Escherichia coli O157[ratio ]H7 infections and haemolytic uraemic syndrome associated with consumption of unpasteurized apple cider}, url={http://dx.doi.org/10.1017/s0950268899003258}, DOI={10.1017/s0950268899003258}, abstractNote={During October 1996, an outbreak of Escherichia coli O157[ratio   ]H7 infections among Connecticut 
residents occurred. An epidemiologic investigation included enhanced surveillance and a case-control study. Clinical isolates of Escherichia coli O157[ratio   ]H7 were typed by pulsed-field gel 
electrophoresis (PFGE). Implicated cider samples were analysed by culture and polymerase 
chain reaction (PCR). Consumption of implicated cider was associated with illness; (matched 
odds ratio = undefined, 95% confidence interval = 3·5–infinity). Ultimately, a total of 14 
outbreak-associated patients were identified. All isolates analysed by PFGE yielded the 
outbreak-associated subtype. Escherichia coli O157[ratio   ]H7 was not cultured from three cider 
samples; PCR analysis detected DNA fragments consistent with Escherichia coli O157[ratio   ]H7 in 
one. This outbreak was associated with drinking one brand of unpasteurized apple cider. 
PFGE subtyping supported the epidemiologic association. PCR analysis detected microbial 
contaminants in the absence of live organisms. Washing and brushing apples did not prevent 
cider contamination.}, journal={Epidemiology and infection}, author={HILBORN, E. D. and MSHAR, P. A. and FIORENTINO, T. R. and DEMBEK, Z. F. and BARRETT, T. J. and HOWARD, R. T. and CARTTER, M. L.}, year={2000} }
 @article{a multistate outbreak of escherichia coli o157:h7 infections associated with consumption of mesclun lettuce._1999, url={https://doi.org/10.1001/archinte.159.15.1758}, DOI={10.1001/archinte.159.15.1758}, abstractNote={BACKGROUND
An outbreak of Escherichia coli O157:H7 infections in Connecticut and Illinois during May 28 to June 27, 1996, was investigated to determine the source of infections.


METHODS
Independent case-control studies were performed in both states. Pulsed-field gel electrophoresis (PFGE) was performed on E. coli O157:H7 isolates. A case-patient was defined as a Connecticut or northern Illinois resident with diarrhea whose stool culture yielded E. coli O157:H7 of the outbreak-associated PFGE subtype. Controls were town-, age-, and sex-matched to case-patients. We traced implicated lettuce to the farm level and performed environmental investigations to identify unsafe lettuce production practices.


RESULTS
In Connecticut and Illinois, infection was associated with consumption of mesclun lettuce (Connecticut matched odds ratio [MOR], undefined; 95% confidence interval [CI], 3.4 to infinity; and Illinois MOR, undefined; 95% CI, 1.4 to infinity). We traced implicated lettuce to a single grower-processor. Cattle, a known E. coli O157:H7 reservoir, were found near the lettuce fields. Escherichia coli (an indicator of fecal contamination) was cultured from wash water and finished lettuce. A trace-forward investigation identified 3 additional states that received implicated lettuce; E. coli O157:H7 isolates from patients in 1 of these states matched the outbreak-associated PFGE subtype.


CONCLUSIONS
This multistate outbreak of E. coli O157:H7 infections was associated with consumption of mesclun lettuce from a single producer. Molecular subtyping facilitated the epidemiological investigation. This investigation increased the knowledge about current production practices that may contribute to the contamination of lettuce by microbial pathogens. Lettuce production practices should be monitored for microbiological safety.}, journal={Archives of internal medicine}, year={1999}, month={Aug} }
 @article{statewide surveillance for ehrlichiosis--connecticut and new york, 1994-1997._1998, journal={MMWR. Morbidity and mortality weekly report}, year={1998}, month={Jun} }
 @article{outbreaks of escherichia coli o157:h7 infection and cryptosporidiosis associated with drinking unpasteurized apple cider--connecticut and new york, october 1996._1997, journal={MMWR. Morbidity and mortality weekly report}, year={1997}, month={Jan} }
 @article{human rabies--connecticut, 1995._1996, journal={MMWR. Morbidity and mortality weekly report}, year={1996}, month={Mar} }
 @article{surveillance for creutzfeldt-jakob disease--united states._1996, journal={MMWR. Morbidity and mortality weekly report}, year={1996}, month={Aug} }
 @article{hilborn_fournie_workgroup_azevedo_chernoff_falconer_hooth_jensen_macphail_stewart_et al., title={Chapter 26: Human Health Effects Workgroup Report}, url={http://citeseerx.ist.psu.edu/viewdoc/summarydoi%3D10.1.1.326.3498}, author={Hilborn, Elizabeth D and Fournie, John W and Workgroup, Members S and Azevedo, Ra Mfo and Chernoff, Neil and Falconer, Ian R and Hooth, Michelle J and Jensen, Karl and Macphail, Robert and Stewart, Ian and et al.} }
 @article{lin_wade_hilborn, title={www.mdpi.com/journal/ijerph Article Flooding and Clostridium difficile Infection: A Case-Crossover Analysis}, url={http://citeseerx.ist.psu.edu/viewdoc/summarydoi%3D10.1.1.696.8105}, author={Lin, Cynthia J. and Wade, Timothy J. and Hilborn, Elizabeth D.} }