Surveillance of Waterborne Disease Outbreaks Associated with Drinking Water - United States, 2015-2020

Problem/Condition

Public health agencies in U.S. states, territories, and freely associated states investigate and voluntarily report waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS). This report summarizes NORS drinking water outbreak epidemiologic, laboratory, and environmental data, including data for both public and private drinking water systems. The report presents outbreak-contributing factors (i.e., practices and factors that lead to outbreaks) and, for the first time, categorizes outbreaks as biofilm pathogen or enteric illness associated.

Period Covered

2015-2020.

Description of System

CDC launched NORS in 2009 as a web-based platform into which public health departments voluntarily enter outbreak information. Through NORS, CDC collects reports of enteric disease outbreaks caused by bacterial, viral, parasitic, chemical, toxin, and unknown agents as well as foodborne and waterborne outbreaks of nonenteric disease. Data provided by NORS users, when known, for drinking water outbreaks include 1) the number of cases, hospitalizations, and deaths; 2) the etiologic agent (confirmed or suspected); 3) the implicated type of water system (e.g., community or individual or private); 4) the setting of exposure (e.g., hospital or health care facility; hotel, motel, lodge, or inn; or private residence); and 5) relevant epidemiologic and environmental data needed to describe the outbreak and characterize contributing factors.

Results

During 2015-2020, public health officials from 28 states voluntarily reported 214 outbreaks associated with drinking water and 454 contributing factor types. The reported etiologies included 187 (87%) biofilm associated, 24 (11%) enteric illness associated, two (1%) unknown, and one (<1%) chemical or toxin. A total of 172 (80%) outbreaks were linked to water from public water systems, 22 (10%) to unknown water systems, 17 (8%) to individual or private systems, and two (0.9%) to other systems; one (0.5%) system type was not reported. Drinking water-associated outbreaks resulted in at least 2,140 cases of illness, 563 hospitalizations (26% of cases), and 88 deaths (4% of cases). Individual or private water systems were implicated in 944 (43%) cases, 52 (9%) hospitalizations, and 14 (16%) deaths.Enteric illness-associated pathogens were implicated in 1,299 (61%) of all illnesses, and 10 (2%) hospitalizations. No deaths were reported. Among these illnesses, three pathogens (norovirus, Shigella, and Campylobacter) or multiple etiologies including these pathogens resulted in 1,225 (94%) cases. The drinking water source was identified most often (n = 34; 7%) as the contributing factor in enteric disease outbreaks. When water source (e.g., groundwater) was known (n = 14), wells were identified in 13 (93%) of enteric disease outbreaks.Most biofilm-related outbreak reports implicated Legionella (n = 184; 98%); two nontuberculous mycobacteria (NTM) (1%) and one Pseudomonas (0.5%) outbreaks comprised the remaining. Legionella-associated outbreaks generally increased over the study period (14 in 2015, 31 in 2016, 30 in 2017, 34 in 2018, 33 in 2019, and 18 in 2020). The Legionella-associated outbreaks resulted in 786 (37%) of all illnesses, 544 (97%) hospitalizations, and 86 (98%) of all deaths. Legionella also was the outbreak etiology in 160 (92%) public water system outbreaks. Outbreak reports cited the premise or point of use location most frequently as the contributing factor for Legionella and other biofilm-associated pathogen outbreaks (n = 287; 63%). Legionella was reported to NORS in 2015 and 2019 as the cause of three outbreaks in private residences (2).

Interpretation

The observed range of biofilm and enteric drinking water pathogen contributing factors illustrate the complexity of drinking water-related disease prevention and the need for water source-to-tap prevention strategies. Legionella-associated outbreaks have increased in number over time and were the leading cause of reported drinking water outbreaks, including hospitalizations and deaths. Enteric illness outbreaks primarily linked to wells represented approximately half the cases during this reporting period. This report enhances CDC efforts to estimate the U.S. illness and health care cost impacts of waterborne disease, which revealed that biofilm-related pathogens, NTM, and Legionella have emerged as the predominant causes of hospitalizations and deaths from waterborne- and drinking water-associated disease.

Public Health Action

Public health departments, regulators, and drinking water partners can use these findings to identify emerging waterborne disease threats, guide outbreak response and prevention programs, and support drinking water regulatory efforts.

Characterization of reported legionellosis outbreaks associated with buildings served by public drinking water systems: United States, 2001-2017

This study examined 184 legionellosis outbreaks in the United States reported to the Centers for Disease Control and Prevention's Waterborne Disease and Outbreak Surveillance System, from 2001 to 2017. Drinking water characteristics examined include source water type, disinfectant type, exposure setting, geographical distribution by U.S. Census Divisions, and the public water system size (population served). This study found that most of the reported drinking water-associated legionellosis outbreaks occurred in eastern United States, including 35% in the South Atlantic, 32% in the Middle Atlantic, and 16% in the East North Central Census Divisions were linked with building water systems in healthcare and hotel settings; and were associated with buildings receiving drinking water from public water systems serving >10,000 people. Targeted evaluations and interventions may be useful to further determine the combination of factors, such as disinfectant residual type and drinking water system size that may lead to legionellosis outbreaks.

Using Wastewater Surveillance Data to Support the COVID-19 Response - United States, 2020-2021

Wastewater surveillance, the measurement of pathogen levels in wastewater, is used to evaluate community-level infection trends, augment traditional surveillance that leverages clinical tests and services (e.g., case reporting), and monitor public health interventions (1). Approximately 40% of persons infected with SARS-CoV-2, the virus that causes COVID-19, shed virus RNA in their stool (2); therefore, community-level trends in SARS-CoV-2 infections, both symptomatic and asymptomatic (2) can be tracked through wastewater testing (3-6). CDC launched the National Wastewater Surveillance System (NWSS) in September 2020 to coordinate wastewater surveillance programs implemented by state, tribal, local, and territorial health departments to support the COVID-19 pandemic response. In the United States, wastewater surveillance was not previously implemented at the national level. As of August 2021, NWSS includes 37 states, four cities, and two territories. This report summarizes NWSS activities and describes innovative applications of wastewater surveillance data by two states, which have included generating alerts to local jurisdictions, allocating mobile testing resources, evaluating irregularities in traditional surveillance, refining health messaging, and forecasting clinical resource needs. NWSS complements traditional surveillance and enables health departments to intervene earlier with focused support in communities experiencing increasing concentrations of SARS-CoV-2 in wastewater. The ability to conduct wastewater surveillance is not affected by access to health care or the clinical testing capacity in the community. Robust, sustainable implementation of wastewater surveillance requires public health capacity for wastewater testing, analysis, and interpretation. Partnerships between wastewater utilities and public health departments are needed to leverage wastewater surveillance data for the COVID-19 response for rapid assessment of emerging threats and preparedness for future pandemics.

Evaluation of Syndromic Surveillance Data for Studying Harmful Algal Bloom-Associated Illnesses - United States, 2017-2019

Harmful algal and cyanobacterial blooms (harmful algal blooms) are large colonies of algae or cyanobacteria that can harm humans, animals, and the environment (1-3). The number of algal blooms has been increasing in the United States, augmented by increasing water temperatures and nutrients in water from industry and agricultural run-off (4,5). The extent to which harmful algal bloom exposures cause human illness or long-term health effects is unknown. As the number of blooms increases annually, the likelihood of negative health outcomes (e.g., respiratory or gastrointestinal illness) from exposure also increases (4,5). To explore the utility of syndromic surveillance data for studying health effects from harmful algal bloom exposures, CDC queried emergency department (ED) visit data from the National Syndromic Surveillance Program (NSSP) for harmful algal bloom exposure-associated administrative discharge diagnosis codes and chief complaint text terms related to harmful algal bloom exposure (6). A total of 321 harmful algal bloom-associated ED visits were identified during January 1, 2017-December 31, 2019. An increase in harmful algal bloom-associated ED visits occurred during warmer months (June-October), consistent with seasonal fluctuations of blooms and recent publications (6,7). Although syndromic surveillance data are helpful for understanding harmful algal bloom-associated ED visits in the United States, exposures were documented infrequently with discharge diagnosis codes; 67% of harmful algal bloom-associated ED visits were identified through querying chief complaint text. Improving the documentation of harmful algal bloom exposures in medical records would further benefit future health studies.

Outbreaks Associated with Untreated Recreational Water - California, Maine, and Minnesota, 2018-2019

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).

Prevention and Control of Youth Camp-Associated Acute Gastroenteritis Outbreaks

BACKGROUND

Approximately 14 million children attend more than 14000 US camps every year. Shared accommodations and activities can facilitate acute gastroenteritis (AGE) outbreaks.

METHODS

We analyzed data from the National Outbreak Reporting System on US youth camp-associated AGE outbreaks that occurred between 2009 and 2016. We also conducted a systematic literature search of youth camp-associated AGE outbreaks that have occurred around the world and a gray literature search for existing recommendations on outbreak prevention and control at camps worldwide.

RESULTS

Thirty-nine US jurisdictions reported a total of 229 youth camp-associated AGE outbreaks to the National Outbreak Reporting System. Of the 226 outbreaks included in our analyses, 120 (53%) were reported to have resulted from person-to-person transmission, 42 (19%) from an unknown transmission mode, 38 (17%) from foodborne transmission, 19 (8%) from waterborne transmission, 5 (2%) from animal contact, and 2 (<1%) from environmental contamination. Among 170 (75%) outbreaks with a single suspected or confirmed etiology, norovirus (107 [63%] outbreaks), Salmonella spp (16 [9%]), and Shiga-toxin producing Escherichia coli (12 [7%]) were implicated most frequently. We identified 43 additional youth camp-associated AGE outbreaks in the literature that occurred in various countries between 1938 and 2014. Control measures identified through the literature search included camp closure, separation of ill campers, environmental disinfection, and education on food preparation and hand hygiene.

CONCLUSIONS

Youth camp-associated AGE outbreaks are caused by numerous pathogens every year. These outbreaks are facilitated by factors that include improper food preparation, inadequate cleaning and disinfection, shared accommodations, and contact with animals. Health education focused on proper hygiene and preventing disease transmission could help control or prevent these outbreaks.

Outbreaks Associated with Untreated Recreational Water - United States, 2000-2014

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.

Outbreaks Associated with Treated Recreational Water - United States, 2000-2014

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.

Foodborne (1973-2013) and Waterborne (1971-2013) Disease Outbreaks - United States

CDC collects data on foodborne and waterborne disease outbreaks reported by all U.S. states and territories through the Foodborne Disease Outbreak Surveillance System (FDOSS) (http://www.cdc.gov/foodsafety/fdoss/surveillance/index.html) and the Waterborne Disease and Outbreak Surveillance System (WBDOSS) http://www.cdc.gov/healthywater/surveillance), respectively. These two systems are the primary source of national data describing the number of reported outbreaks; outbreak-associated illnesses, hospitalizations, and deaths; etiologic agents; water source or implicated foods; settings of exposure; and other factors associated with recognized foodborne and waterborne disease outbreaks in the United States.

Contributing factors to disease outbreaks associated with untreated groundwater

Disease outbreaks associated with drinking water drawn from untreated groundwater sources represent a substantial proportion (30.3%) of the 818 drinking water outbreaks reported to CDC's Waterborne Disease and Outbreak Surveillance System (WBDOSS) during 1971 to 2008. The objectives of this study were to identify underlying contributing factors, suggest improvements for data collection during outbreaks, and inform outbreak prevention efforts. Two researchers independently reviewed all qualifying outbreak reports (1971 to 2008), assigned contributing factors and abstracted additional information (e.g., cases, etiology, and water system attributes). The 248 outbreaks resulted in at least 23,478 cases of illness, 390 hospitalizations, and 13 deaths. The majority of outbreaks had an unidentified etiology (n = 135, 54.4%). When identified, the primary etiologies were hepatitis A virus (n = 21, 8.5%), Shigella spp. (n = 20, 8.1%), and Giardia intestinalis (n = 14, 5.7%). Among the 172 (69.4%) outbreaks with contributing factor data available, the leading contamination sources included human sewage (n = 57, 33.1%), animal contamination (n = 16, 9.3%), and contamination entering via the distribution system (n = 12, 7.0%). Groundwater contamination was most often facilitated by improper design, maintenance or location of the water source or nearby waste water disposal system (i.e., septic tank; n = 116, 67.4%). Other contributing factors included rapid pathogen transport through hydrogeologic formations (e.g., karst limestone; n = 45, 26.2%) and preceding heavy rainfall or flooding (n = 36, 20.9%). This analysis underscores the importance of identifying untreated groundwater system vulnerabilities through frequent inspection and routine maintenance, as recommended by protective regulations such as Environmental Protection Agency's (EPA's) Groundwater Rule, and the need for special consideration of the local hydrogeology.

Acute gastroenteritis surveillance through the National Outbreak Reporting System, United States

Implemented in 2009, the National Outbreak Reporting System provides surveillance for acute gastroenteritis outbreaks in the United States resulting from any transmission mode. Data from the first 2 years of surveillance highlight the predominant role of norovirus. The pathogen-specific transmission pathways and exposure settings identified can help inform prevention efforts.

Algal bloom-associated disease outbreaks among users of freshwater lakes--United States, 2009-2010

Harmful algal blooms (HABs) are excessive accumulations of microscopic photosynthesizing aquatic organisms (phytoplankton) that produce biotoxins or otherwise adversely affect humans, animals, and ecosystems. HABs occur sporadically and often produce a visible algal scum on the water. This report summarizes human health data and water sampling results voluntarily reported to CDC's Waterborne Disease and Outbreak Surveillance System (WBDOSS) via the National Outbreak Reporting System (NORS) and the Harmful Algal Bloom-Related Illness Surveillance System (HABISS)* for the years 2009-2010. For 2009-2010, 11 waterborne disease outbreaks associated with algal blooms were reported; these HABs all occurred in freshwater lakes. The outbreaks occurred in three states and affected at least 61 persons. Health effects included dermatologic, gastrointestinal, respiratory, and neurologic signs and symptoms. These 11 HAB-associated outbreaks represented 46% of the 24 outbreaks associated with untreated recreational water reported for 2009-2010, and 79% of the 14 freshwater HAB-associated outbreaks that have been reported to CDC since 1978. Clinicians should be aware of the potential for HAB-associated illness among patients with a history of exposure to freshwater.

Recreational water-associated disease outbreaks--United States, 2009-2010

Recreational water-associated disease outbreaks result from exposure to infectious pathogens or chemical agents in treated recreational water venues (e.g., pools and hot tubs or spas) or untreated recreational water venues (e.g., lakes and oceans). For 2009-2010, the most recent years for which finalized data are available, public health officials from 28 states and Puerto Rico electronically reported 81 recreational water-associated disease outbreaks to CDC's Waterborne Disease and Outbreak Surveillance System (WBDOSS) via the National Outbreak Reporting System (NORS). This report summarizes the characteristics of those outbreaks. Among the 57 outbreaks associated with treated recreational water, 24 (42%) were caused by Cryptosporidium. Among the 24 outbreaks associated with untreated recreational water, 11 (46%) were confirmed or suspected to have been caused by cyanobacterial toxins. In total, the 81 outbreaks resulted in at least 1,326 cases of illness and 62 hospitalizations; no deaths were reported. Laboratory and environmental data, in addition to epidemiologic data, can be used to direct and optimize the prevention and control of recreational water-associated disease outbreaks.

Surveillance for waterborne disease outbreaks and other health events associated with recreational water --- United States, 2007--2008

PROBLEM/CONDITION

Since 1978, CDC, the U.S. Environmental Protection Agency, and the Council of State and Territorial Epidemiologists have collaborated on the Waterborne Disease and Outbreak Surveillance System (WBDOSS) for collecting and reporting data on waterborne disease outbreaks associated with recreational water. This surveillance system is the primary source of data concerning the scope and health effects of waterborne disease outbreaks in the United States. In addition, data are collected on other select recreational water--associated health events, including pool chemical--associated health events and single cases of Vibrio wound infection and primary amebic meningoencephalitis (PAM).

REPORTING PERIOD

Data presented summarize recreational water--associated outbreaks and other health events that occurred during January 2007--December 2008. Previously unreported data on outbreaks that have occurred since 1978 also are presented.

DESCRIPTION OF THE SYSTEM

The WBDOSS database includes data on outbreaks associated with recreational water, drinking water, water not intended for drinking (excluding recreational water), and water use of unknown intent. Public health agencies in the states, the District of Columbia, U.S. territories, and Freely Associated States are primarily responsible for detecting and investigating waterborne disease outbreaks and voluntarily reporting them to CDC using a standard form. Only data on outbreaks associated with recreational water are summarized in this report. Data on other recreational water--associated health events reported to CDC, the Agency for Toxic Substances and Disease Registry (ATSDR), and the U.S. Consumer Product Safety Commission (CPSC) also are summarized.

RESULTS

A total of 134 recreational water--associated outbreaks were reported by 38 states and Puerto Rico for 2007--2008. These outbreaks resulted in at least 13,966 cases. The median outbreak size was 11 cases (range: 2--5,697 cases). A total of 116 (86.6%) outbreaks were associated with treated recreational water (e.g., pools and interactive fountains) and resulted in 13,480 (96.5%) cases. Of the 134 outbreaks, 81 (60.4%) were outbreaks of acute gastrointestinal illness (AGI); 24 (17.9%) were outbreaks of dermatologic illnesses, conditions, or symptoms; and 17 (12.7%) were outbreaks of acute respiratory illness. Outbreaks of AGI resulted in 12,477 (89.3%) cases. The etiology was laboratory-confirmed for 105 (78.4%) of the 134 outbreaks. Of the 105 outbreaks with a laboratory-confirmed etiology, 68 (64.8%) were caused by parasites, 22 (21.0%) by bacteria, five (4.8%) by viruses, nine (8.6%) by chemicals or toxins, and one (1.0%) by multiple etiology types. Cryptosporidium was confirmed as the etiologic agent of 60 (44.8%) of 134 outbreaks, resulting in 12,154 (87.0%) cases; 58 (96.7%) of these outbreaks, resulting in a total of 12,137 (99.9%) cases, were associated with treated recreational water. A total of 32 pool chemical--associated health events that occurred in a public or residential setting were reported to WBDOSS by Maryland and Michigan. These events resulted in 48 cases of illness or injury; 26 (81.3%) events could be attributed at least partially to chemical handling errors (e.g., mixing incompatible chemicals). ATSDR's Hazardous Substance Emergency Events Surveillance System received 92 reports of hazardous substance events that occurred at aquatic facilities. More than half of these events (55 [59.8%]) involved injured persons; the most frequently reported primary contributing factor was human error. Estimates based on CPSC's National Electronic Injury Surveillance System (NEISS) data indicate that 4,574 (95% confidence interval [CI]: 2,703--6,446) emergency department (ED) visits attributable to pool chemical--associated injuries occurred in 2008; the most frequent diagnosis was poisoning (1,784 ED visits [95% CI: 585--2,984]). NEISS data indicate that pool chemical--associated health events occur frequently in residential settings. A total of 236 Vibrio wound infections were reported to be associated with recreational water exposure; 36 (48.6%) of the 74 hospitalized vibriosis patients and six (66.7%) of the nine vibriosis patients who died had V. vulnificus infections. Eight fatal cases of PAM occurred after exposure to warm untreated freshwater.

INTERPRETATIONS

The 134 recreational water--associated outbreaks reported for 2007--2008 represent a substantial increase over the 78 outbreaks reported for 2005--2006 and the largest number of outbreaks ever reported to WBDOSS for a 2-year period. Outbreaks, especially the largest ones, were most frequently associated with treated recreational water and characterized by AGI. Cryptosporidium remains the leading etiologic agent. Pool chemical--associated health events occur frequently but are preventable. Data on other select recreational water--associated health events further elucidate the epidemiology of U.S. waterborne disease by highlighting less frequently implicated types of recreational water (e.g., oceans) and detected types of recreational water--associated illness (i.e., not AGI).

PUBLIC HEALTH ACTIONS

CDC uses waterborne disease outbreak surveillance data to 1) identify the types of etiologic agents, recreational water venues, and settings associated with waterborne disease outbreaks; 2) evaluate the adequacy of regulations and public awareness activities to promote healthy and safe swimming; and 3) establish public health priorities to improve prevention efforts, guidelines, and regulations at the local, state, and federal levels.

Surveillance for waterborne disease outbreaks associated with drinking water---United States, 2007--2008

PROBLEM/CONDITION

Since 1971, CDC, the Environmental Protection Agency (EPA), and the Council of State and Territorial Epidemiologists have collaborated on the Waterborne Disease and Outbreak Surveillance System (WBDOSS) for collecting and reporting data related to occurrences and causes of waterborne disease outbreaks associated with drinking water. This surveillance system is the primary source of data concerning the scope and health effects of waterborne disease outbreaks in the United States.

REPORTING PERIOD

Data presented summarize 48 outbreaks that occurred during January 2007--December 2008 and 70 previously unreported outbreaks.

DESCRIPTION OF SYSTEM

WBDOSS includes data on outbreaks associated with drinking water, recreational water, water not intended for drinking (WNID) (excluding recreational water), and water use of unknown intent (WUI). Public health agencies in the states, U.S. territories, localities, and Freely Associated States are primarily responsible for detecting and investigating outbreaks and reporting them voluntarily to CDC by a standard form. Only data on outbreaks associated with drinking water, WNID (excluding recreational water), and WUI are summarized in this report. Outbreaks associated with recreational water are reported separately.

RESULTS

A total of 24 states and Puerto Rico reported 48 outbreaks that occurred during 2007--2008. Of these 48 outbreaks, 36 were associated with drinking water, eight with WNID, and four with WUI. The 36 drinking water--associated outbreaks caused illness among at least 4,128 persons and were linked to three deaths. Etiologic agents were identified in 32 (88.9%) of the 36 drinking water--associated outbreaks; 21 (58.3%) outbreaks were associated with bacteria, five (13.9%) with viruses, three (8.3%) with parasites, one (2.8%) with a chemical, one (2.8%) with both bacteria and viruses, and one (2.8%) with both bacteria and parasites. Four outbreaks (11.1%) had unidentified etiologies. Of the 36 drinking water--associated outbreaks, 22 (61.1%) were outbreaks of acute gastrointestinal illness (AGI), 12 (33.3%) were outbreaks of acute respiratory illness (ARI), one (2.8%) was an outbreak associated with skin irritation, and one (2.8%) was an outbreak of hepatitis. All outbreaks of ARI were caused by Legionella spp. A total of 37 deficiencies were identified in the 36 outbreaks associated with drinking water. Of the 37 deficiencies, 22 (59.5%) involved contamination at or in the source water, treatment facility, or distribution system; 13 (35.1%) occurred at points not under the jurisdiction of a water utility; and two (5.4%) had unknown/insufficient deficiency information. Among the 21 outbreaks associated with source water, treatment, or distribution system deficiencies, 13 (61.9%) were associated with untreated ground water, six (28.6%) with treatment deficiencies, one (4.8%) with a distribution system deficiency, and one (4.8%) with both a treatment and a distribution system deficiency. No outbreaks were associated with untreated surface water. Of the 21 outbreaks, 16 (76.2%) occurred in public water systems (drinking water systems under the jurisdiction of EPA regulations and water utility management), and five (23.8%) outbreaks occurred in individual systems (all of which were associated with untreated ground water). Among the 13 outbreaks with deficiencies not under the jurisdiction of a water system, 12 (92.3%) were associated with the growth of Legionella spp. in the drinking water system, and one (7.7%) was associated with a plumbing deficiency. In the two outbreaks with unknown deficiencies, one was associated with a public water supply, and the other was associated with commercially bottled water. The 70 previously unreported outbreaks included 69 Legionella outbreaks during 1973--2000 that were not reportable previously to WBDOSS and one previously unreported outbreak from 2002.

INTERPRETATION

More than half of the drinking water--associated outbreaks reported during the 2007--2008 surveillance period were associated with untreated or inadequately treated ground water, indicating that contamination of ground water remains a public health problem. The majority of these outbreaks occurred in public water systems that are subject to EPA's new Ground Water Rule (GWR), which requires the majority of community water systems to complete initial sanitary surveys by 2012. The GWR focuses on identification of deficiencies, protection of wells and springs from contamination, and providing disinfection when necessary to protect against bacterial and viral agents. In addition, several drinking water--associated outbreaks that were related to contaminated ground water appeared to occur in systems that were potentially under the influence of surface water. Future efforts to collect data systematically on contributing factors associated with drinking water outbreaks and deficiencies, including identification of ground water under the direct influence of surface water and the criteria used for their classification, would be useful to better assess risks associated with ground water. During 2007--2008, Legionella was the most frequently reported etiology among drinking water--associated outbreaks, following the pattern observed since it was first included in WBDOSS in 2001. However, six (50%) of the 12 drinking water--associated Legionella outbreaks were reported from one state, highlighting the substantial variance in outbreak detection and reporting across states and territories. The addition of published and CDC-investigated legionellosis outbreaks to the WBDOSS database clarifies that Legionella is not a new public health issue. During 2009, Legionella was added to EPA's Contaminant Candidate List for the first time.

PUBLIC HEALTH ACTIONS

CDC and EPA use WBDOSS surveillance data to identify the types of etiologic agents, deficiencies, water systems, and sources associated with waterborne disease outbreaks and to evaluate the adequacy of current technologies and practices for providing safe drinking water. Surveillance data also are used to establish research priorities, which can lead to improved water quality regulation development. Approximately two thirds of the outbreaks associated with untreated ground water reported during the 2007--2008 surveillance period occurred in public water systems. When fully implemented, the GWR that was promulgated in 2006 is expected to result in decreases in ground water outbreaks, similar to the decreases observed in surface water outbreaks after enactment of the Surface Water Treatment Rule in 1974 and its subsequent amendments. One third of drinking water--associated outbreaks occurred in building premise plumbing systems outside the jurisdiction of water utility management and EPA regulations; Legionella spp. accounted for >90% of these outbreaks, indicating that greater attention is needed to reduce the risk for legionellosis in building plumbing systems. Finally, a large communitywide drinking water outbreak occurred in 2008 in a public water system associated with a distribution system deficiency, underscoring the importance of maintaining and upgrading drinking water distribution system infrastructure to provide safe water and protect public health.

Protein docking using continuum electrostatics and geometric fit

The computer program DOT quickly finds low-energy docked structures for two proteins by performing a systematic search over six degrees of freedom. A novel feature of DOT is its energy function, which is the sum of both a Poisson-Boltzmann electrostatic energy and a van der Waals energy, each represented as a grid-based correlation function. DOT evaluates the energy of interaction for many orientations of the moving molecule and maintains separate lists scored by either the electrostatic energy, the van der Waals energy or the composite sum of both. The free energy is obtained by summing the Boltzmann factor over all rotations at each grid point. Three important findings are presented. First, for a wide variety of protein-protein interactions, the composite-energy function is shown to produce larger clusters of correct answers than found by scoring with either van der Waals energy (geometric fit) or electrostatic energy alone. Second, free-energy clusters are demonstrated to be indicators of binding sites. Third, the contributions of electrostatic and attractive van der Waals energies to the total energy term appropriately reflect the nature of the various types of protein-protein interactions studied.

Stabilization of bound polycyclic aromatic hydrocarbons by a pi-cation interaction

Proteins can use aromatic side-chains to stabilize bound cationic ligands through cation-pi interactions. Here, we report the first example of the reciprocal process, termed pi-cation, in which a cationic protein side-chain stabilizes a neutral aromatic ligand. Site-directed mutagenesis revealed that an arginine side-chain located in the deep binding pocket of a monoclonal antibody (4D5) is essential for binding the neutral polynuclear aromatic hydrocarbon benzo[a]pyrene. This Arg was very likely selected for in the primary response, further underscoring the importance of the pi-cation interaction for ligand binding, which should be considered in protein analysis and design when ligands include aromatic groups.

Definition of the interaction domain for cytochrome c on cytochrome c oxidase. III. Prediction of the docked complex by a complete, systematic search

The electron transfer complex between bovine cytochrome c oxidase and horse cytochrome c has been predicted with the docking program DOT, which performs a complete, systematic search over all six rotational and translational degrees of freedom. Energies for over 36 billion configurations were calculated, providing a free-energy landscape showing guidance of positively charged cytochrome c to the negative region on the cytochrome c oxidase surface formed by subunit II. In a representative configuration, the solvent-exposed cytochrome c heme edge is within 4 A of the indole ring of subunit II residue Trp(104), indicating a likely electron transfer path. These two groups are surrounded by a small, hydrophobic contact region, which is surrounded by electrostatically complementary hydrophilic interactions. Cytochrome c/cytochrome c oxidase interactions of Lys(13) with Asp(119) and Lys(72) with Gln(103) and Asp(158) are the most critical polar interactions due to their proximity to the hydrophobic region and exclusion from bulk solvent. The predicted complex matches previous mutagenesis, binding, and time-resolved kinetics studies that implicate Trp(104) in electron transfer and show the importance of specific charged residues to protein affinity. Electrostatic forces not only enhance long range protein/protein association; they also predominate in short range alignment, creating the transient interaction needed for rapid turnover.

Structural basis for amide hydrolysis catalyzed by the 43C9 antibody

Among catalytic antibodies, the well-characterized antibody 43C9 is unique in its ability to catalyze the difficult, but desirable, reaction of selective amide hydrolysis. The crystallographic structures that we present here for the single-chain variable fragment of the 43C9 antibody, both with and without the bound product p -nitrophenol, strongly support and extend the structural and mechanistic information previously provided by a three-dimensional computational model, together with extensive biochemical, kinetics, and mutagenesis results. The structures reveal an unexpected extended beta-sheet conformation of the third complementarity determining region of the heavy chain, which may be coupled to the novel indole ring orientation of the adjacent Trp H103. This unusual conformation creates an antigen-binding site that is significantly deeper than predicted in the computational model, with a hydrophobic pocket that encloses the p -nitrophenol product. Despite these differences, the previously proposed roles for Arg L96 in transition-state stabilization and for His L91 as the nucleophile that forms a covalent acyl-antibody intermediate are fully supported by the crystallographic structures. His L91 is now centered at the bottom of the antigen-binding site with the imidazole ring poised for nucleophilic attack. His L91, Arg L96, and the bound p -nitrophenol are linked into a hydrogen-bonding network by two well-ordered water molecules. These water molecules may mimic the positions of the phosphonamidate oxygen atoms of the antigen, which in turn mimic the transition state of the reaction. This network also contains His H35, suggesting that this residue may also stabilize the transition-states. A possible proton-transfer pathway from His L91 through two tyrosine residues may assist nucleophilic attack. Although transition-state stabilization is commonly observed in esterolytic antibodies, nucleophilic attack appears to be unique to 43C9 and accounts for the unusually high catalytic activity of this antibody.

Unraveling the effect of changes in conformation and compactness at the antibody V(L)-V(H) interface upon antigen binding

We have analyzed conformational changes that occur at the interface between the light (V(L)) and heavy (V(H)) chains in antibody variable fragments upon binding to antigens. We wrote and applied the Tiny Probe program that computes the buried atomic contact surface area of three-dimensional structures to evaluate changes in compactness of the V(L)-V(H) interface between bound and unbound antibodies. We found three categories of these changes, which correlated with the size of the antigen. Upon binding, medium-sized nonprotein antigens cause an opening of the V(L)-V(H) interface (less compact), small antigens or haptens cause a closure of the interface (more compact), whereas large protein antigens have little effect on the compactness of the V(L)-V(H) interface. The largest changes in the atomic buried contact surface area at the V(L)-V(H) interface occur in residue pairs providing two 'shock absorbers' between the edge beta-strands of the V(L) and V(H) beta-sheets forming the antibody binding site. Importantly, the correlation between the size of antigens and conformational changes indicates that the V(L)-V(H) interface in antibodies plays a significant role in the antigen binding process. Furthermore, as the energy involved in such a motion is significant (up to 3 kcal/mol), these results provide a general mechanism for how residues distant from the combining site can significantly alter the affinity of an antibody for its antigen. Thus, mutations introduced at the V(L)-V(H) interface can be used to change antibody binding affinity with antigens. Due to the tightly packed V(L)-V(H) interface, the introduction of random mutations is not advisable. Rather our analysis suggests that concerted mutations of residues preceding CDRL2 and following CDRH3 or residues preceding CDRH2 and at the end of CDRL3 are most likely to alter or improve antigen binding affinity.

Complex formation between Azotobacter vinelandii ferredoxin I and its physiological electron donor NADPH-ferredoxin reductase

In Azotobacter vinelandii, deletion of the fdxA gene, which encodes ferredoxin I (FdI), leads to activation of the expression of the fpr gene, which encodes NADPH-ferredoxin reductase (FPR). In order to investigate the relationship of these two proteins further, the interactions of the two purified proteins have been examined. AvFdI forms a specific 1:1 cross-linked complex with AvFPR through ionic interactions formed between the Lys residues of FPR and Asp/Glu residues of FdI. The Lys in FPR has been identified as Lys258, a residue that forms a salt bridge with one of the phosphate oxygens of FAD in the absence of FdI. UV-Vis and circular dichroism data show that on binding FdI, the spectrum of the FPR flavin is hyperchromatic and red-shifted, confirming the interaction region close to the FAD. Cytochrome c reductase assays and electron paramagnetic resonance data show that electron transfer between the two proteins is pH-dependent and that the [3Fe-4S]+ cluster of FdI is specifically reduced by NADPH via FPR, suggesting that the [3Fe-4S] cluster is near FAD in the complex. To further investigate the FPR:FdI interaction, the electrostatic potentials for each protein were calculated. Strongly negative regions around the [3Fe-4S] cluster of FdI are electrostatically complementary with a strongly positive region overlaying the FAD of FPR, centered on Lys258. These proposed interactions of FdI with FPR are consistent with cross-linking, peptide mapping, spectroscopic, and electron transfer data and strongly support the suggestion that the two proteins are physiological redox partners.

Monoclonal antibody-based ELISAs for part-per-billion determination of polycyclic aromatic hydrocarbons: effects of haptens and formats on sensitivity and specificity

As a first step toward developing sensitive enzyme-linked immunosorbent assays (ELISAs) for multianalyte detection of polycyclic aromatic hydrocarbons (PAHs), haptens with different lengths of carboxylic acid spacers at various positions were derived from naphthalene, fluorene, anthracene, phenanthrene, pyrene, fluoranthene, chrysene, and benzo[a]pyrene (BaP). These haptens were coupled with bovine serum albumin (BSA) to form competitor conjugates. All of these haptens were recognized to different extents by monoclonal antibodies (MAbs) 4D5 and 10C10 originally derived by Gomes and Santella (Chem. Res. Toxicol. 1990, 3, 307-310). The most sensitive indirect ELISAs were obtained by coating wells with the least competitive conjugates. Direct ELISAs using horseradish peroxidase conjugates of pyrene and BaP were less sensitive. The MAbs bound BaP with spacers at either C1 or C6. The cross-reactivity profiles of the eight PAHs were different with each PAH-BSA conjugate used as coating antigen. The ELISA results for BaP closely correlated with those by gas chromatography (GC), but the detection limit of the ELISA was approximately 150-fold more sensitive than that of GC, with 2-600 nM spike recoveries of 80-127% from human urine and canal and tap water.

Harmful somatic mutations: lessons from the dark side

The ability of somatic mutation to modify the course of an immune response is well documented. However, emphasis has been placed almost exclusively on the ability of somatic mutation to improve the functional characteristics of representative antibodies. The harmful effects of somatic mutation, its dark side, have been far less well characterized. Yet evidence suggests that the number of B cells directed to wastage pathways as a result of harmful somatic mutation probably far exceeds the number of cells whose antibodies have been improved. Here we review our recent findings in understanding the structural and functional consequences of V-region mutation.

Consensus chemistry and beta-turn conformation of the active core of the insect kinin neuropeptide family

BACKGROUND

Neuropeptides are examples of small, flexible molecules that bind to receptors and induce signal transduction, thereby eliciting biological activity. The multifunctional insect kinin neuropeptides retain full activity when reduced to only their carboxy-terminal pentapeptide (Phe1-X2-X3-Trp4-Gly5-NH2), thereby allowing extensive structure-function studies and conformational analysis.

RESULTS

A combined experimental and theoretical analysis of the insect kinin carboxy-terminal pentapeptide was used to probe the role of each residue, define the bioactive conformation, and design a constrained bioactive analog. Coupling receptor-binding data with two biological activity assays allowed receptor binding and signal transduction to be differentiated. A preferred beta-turn conformation, found for residues 1-4 by molecular dynamics simulations, was tested by designing a conformationally restricted cyclic hexapeptide. This cyclic analog showed a preference for the beta-turn conformation, as shown by a conformational search and nuclear magnetic resonance spectroscopy, and it showed stronger receptor binding but decreased activity relative to highly active linear analogs.

CONCLUSIONS

Each residue of the insect kinin carboxy-terminal pentapeptide has a distinct role in conformational preference, specific receptor interactions or signal transduction. The beta-turn preference of residues Phe1-X2-X3-Trp4 implicates this as the bioactive conformation. The amidated carboxyl terminus, required for activity in many neuropeptide families, may be generally important for signal transduction and its inclusion may therefore be essential for agonist design.

Tolerance of single, but not multiple, amino acid replacements in antibody VH CDR 2: a means of minimizing B cell wastage from somatic hypermutation?

Mutations in the heavy chain complementarity determining region 2 (CDR2) of the phosphocholine-specific T15 Ab can have a dramatic effect on the ability of the Ab to bind Ag. A panel of multisite mutants that had lost detectable binding to phosphocholine-containing Ags was previously created by saturation mutagenesis of the CDR2 region of T15. Based on the predicted importance of amino acid changes represented in the multisite mutants, we have created single-site mutations, yielding a panel of Abs with which to test 17 of the 19 CDR2 residues. Of the 17 positions examined, only one, Arg52, is intolerant to change, yielding a nonbinder phenotype even with conservative amino acid replacement. Mutation at two other sites, Ala50 and Tyr55, can yield a nonbinder phenotype depending on the amino acid replacement. Single-site mutations of the remaining 14 positions allowed retention of binding ability. Thus, except for positions 50, 52, and 55, multiple mutations must be introduced into the CDR2 region to create a nonbinder phenotype. We provide a newly refined model of T15, illustrating the structure and the interactions of the CDR2 region. Our results imply that introduction of point mutations would not normally delete Ag-binding ability until two or more mutations had accumulated. This would minimize potentially harmful effects of somatic mutation on Ig V region genes and improve the chance of survival for an Ab such as T15, which in its unmutated form is already well suited to bind Ag.

Tolerance of single, but not multiple, amino acid replacements in antibody VH CDR 2: a means of minimizing B cell wastage from somatic hypermutation?

Mutations in the heavy chain complementarity determining region 2 (CDR2) of the phosphocholine-specific T15 Ab can have a dramatic effect on the ability of the Ab to bind Ag. A panel of multisite mutants that had lost detectable binding to phosphocholine-containing Ags was previously created by saturation mutagenesis of the CDR2 region of T15. Based on the predicted importance of amino acid changes represented in the multisite mutants, we have created single-site mutations, yielding a panel of Abs with which to test 17 of the 19 CDR2 residues. Of the 17 positions examined, only one, Arg52, is intolerant to change, yielding a nonbinder phenotype even with conservative amino acid replacement. Mutation at two other sites, Ala50 and Tyr55, can yield a nonbinder phenotype depending on the amino acid replacement. Single-site mutations of the remaining 14 positions allowed retention of binding ability. Thus, except for positions 50, 52, and 55, multiple mutations must be introduced into the CDR2 region to create a nonbinder phenotype. We provide a newly refined model of T15, illustrating the structure and the interactions of the CDR2 region. Our results imply that introduction of point mutations would not normally delete Ag-binding ability until two or more mutations had accumulated. This would minimize potentially harmful effects of somatic mutation on Ig V region genes and improve the chance of survival for an Ab such as T15, which in its unmutated form is already well suited to bind Ag.

Humanization and molecular modeling of the anti-CD4 monoclonal antibody, OKT4A

OKT4A, a murine mAb that recognizes an epitope on the CD4 receptor, is a potent immunosuppressive agent in vitro and in a variety of nonhuman primate models of graft rejection and autoimmune disease. Initial human cardiac transplant trials suggest that OKT4A does not cause either cytokine release syndrome or CD4+ cell depletion, but does induce a human anti-mouse Ab (HAMA) response despite strong concurrent immunosuppression. To further investigate the potential of OKT4A as an immunomodulator, it was necessary to decrease its immunogenicity. Therefore, we developed a humanized version of this Ab (gOKT4A-4), which has the same binding affinity and in vitro immunosuppressive properties of OKT4A, but retains only three murine sequence-derived amino acid residues outside of the complementarity-determining regions (CDRs). Detailed computer modeling of both OKT4A and gOKT4A-4 provided a computational rationale for the changes necessary to regain activity after humanization. This has also provided a plausible representation of the Ag binding site. Preliminary clinical results with gOKT4A-4 suggest that we have eliminated the immunogenicity observed in the parent murine Ab.

Humanization and molecular modeling of the anti-CD4 monoclonal antibody, OKT4A

OKT4A, a murine mAb that recognizes an epitope on the CD4 receptor, is a potent immunosuppressive agent in vitro and in a variety of nonhuman primate models of graft rejection and autoimmune disease. Initial human cardiac transplant trials suggest that OKT4A does not cause either cytokine release syndrome or CD4+ cell depletion, but does induce a human anti-mouse Ab (HAMA) response despite strong concurrent immunosuppression. To further investigate the potential of OKT4A as an immunomodulator, it was necessary to decrease its immunogenicity. Therefore, we developed a humanized version of this Ab (gOKT4A-4), which has the same binding affinity and in vitro immunosuppressive properties of OKT4A, but retains only three murine sequence-derived amino acid residues outside of the complementarity-determining regions (CDRs). Detailed computer modeling of both OKT4A and gOKT4A-4 provided a computational rationale for the changes necessary to regain activity after humanization. This has also provided a plausible representation of the Ag binding site. Preliminary clinical results with gOKT4A-4 suggest that we have eliminated the immunogenicity observed in the parent murine Ab.

A nonpeptidal peptidomimetic agonist of the insect FLRFamide myosuppressin family

Benzethonium chloride (Bztc) is the first totally nonpeptide ligand for an insect, indeed an invertebrate, peptide receptor. Bztc mimics the inhibitory physiological activity of the myosuppressins, a subfamily of the FLRFamides, in three different insect bioassay systems. The inhibitory action of leucomyosuppressin and the nonpeptide Bztc in both the cockroach hindgut and the mealworm neuromuscular junction can be blocked by the lipoxygenase inhibitor, nordihydroguaiaretic acid, providing evidence for similar modes of action. Lipoxygenase metabolites of arachidonic acid may mediate inhibition of neuromuscular transmission by these two factors. In addition, Bztc competitively displaces a radiolabeled myosuppressin analogue from high- and low-affinity receptors of the locust oviduct. Thus, the nonpeptide interacts with both binding and activating regions of myosuppressin receptors. Molecular dynamics experiments in which selected functional groups of Bztc were fit onto corresponding functional groups of low-energy myosuppressin pentapeptide structures indicate how Bztc may mimic the myosuppressins at a molecular level. The discovery of Bztc as a nonpeptidal peptidomimetic analogue provides an opportunity to develop new pest management strategies by targeting an insect's own peptide receptor.

Pseudodipeptide analogs of the pyrokinin/PBAN (FXPRLa) insect neuropeptide family containing carbocyclic Pro-mimetic conformational components

Three N-terminal amino acid residues of the C-terminal core pentapeptide Phe-X-Pro-Arg-Leu-NH2 (X = Gly, Ser, Thr, Val) of the pryokinin/PBAN insect neuropeptide family were replaced by nonpeptide moieties. To reestablish some of the conformational properties lost upon removal of the peptide bonds and Pro of the three amino acid residue block, carbocyclic Pro-mimetic components were incorporated into pseudodipeptide analogs. The most active analog contained a trans-DL-1,2-cyclopentanedicarboxyl carbocyclic component and proved to be over 3 orders of magnitude more potent than a simple, straight chain pseudodipeptide analog and approached the potency of the pentapeptide core in a cockroach hindgut myotropic bioassay. The pseudodipeptide analog retains a critical carbonyl residue which can participate in a hydrogen bond that stabilizes a beta-turn conformation in the active core region of the pyrokinin/PBAN peptides. This study demonstrates that knowledge of active conformation can be used to enhance the biological potency of pseudopeptide mimetic analogs of insect neuropeptides. The analogs represent a milestone in the development of pseudopeptide and nonpeptide mimetic analogs of this peptide family, which has been associated with such critical physiological processes as hindgut and oviduct contraction, pheromone biosynthesis, diapause induction, and induction of melanization and reddish coloration in a variety of insects. Mimetic analogs are potentially valuable tools to insect neuroendocrinologists studying these physiological processes and/or engaged in the development of future pest management strategies.

Enhancement and destruction of antibody function by somatic mutation: unequal occurrence is controlled by V gene combinatorial associations

We examined the positive and negative effects of somatic mutation on antibody function using saturation mutagenesis in vitro to mimic the potential of the in vivo process to diversify antibodies. Identical mutations were introduced into the second complementarity determining region of two anti-phosphocholine antibodies, T15 and D16, which share the same germline VH gene sequence. T15 predominates in primary responses and does not undergo affinity maturation. D16 is representative of antibodies that co-dominate in memory responses and do undergo affinity maturation. We previously reported that > 50% of T15 mutants had decreased antigen binding capacity. To test if this high frequency of binding loss was unique to T15 or a consequence of random point mutations applicable to other combining sites, we analyzed the same mutations in D16. We show that D16 suffers a similar loss of function, indicating an equally high potential for B-cell wastage. However, only D16 displayed the capacity for somatic mutation to improve antigen binding, which should enhance its persistence in memory responses. Mutation of residues contacting the haptenic group, as determined by molecular modeling, did not improve binding. Instead, productive mutations occurred in residues that either contacted carrier protein or were distant from the antigen binding site, possibly increasing binding site flexibility through long-range effects. Targeting such residues for mutation should aid in the rational design of improved antibodies.

Metalloantibody design

Metal-binding sites were designed within the antigen-binding pocket of the catalytic antibody 43C9 based on a 3-dimensional antibody model and crystallographic structures of Zn-binding metalloenzymes. These tetrahedral Zn-binding sites were designed to mimic both secondary and tertiary structural characteristics of catalytic metal sites in enzymes. Each site was planned to have two His ligands across from each other on adjacent antiparallel beta-strands. Sites were selected to sequester the metal ion from bulk solvent and place an open metal coordination position next to the antigen or potential substrates. Three distinct metal-site designs, with ligands in the variable light domain, in the variable heavy domain, and in both domains, were later implemented experimentally and shown spectroscopically to bind metal ions as predicted. These results demonstrate the success of our design approach, the versatility of the antibody structure for metalloprotein design, and the validity of the 3-dimensional model. The ability to predictably design multiple metal sites in the ordered antigen-recognition region at the bottom of the pocket allows tuning of metal ion placement and enhances the likelihood of interaction with putative substrates.

Predicting molecular interactions and inducible complementarity: fragment docking of Fab-peptide complexes

Antibody-antigen interactions are representative of a broad class of receptor-ligand interactions involving both specificity and potential inducible complementarity. To test possible mechanisms of antigen-antibody recognition and specificity computationally, we have used a Metropolis Monte Carlo algorithm to dock fragments of the epitope Glu-Val-Val-Pro-His-Lys-Lys to the X-ray structures of both the free and the complexed Fab of the antibody B13I2 (raised against the C-helix of myohemerythrin). The fragments Pro-His and Val-Pro-His, which contain residues experimentally identified as important for binding, docked correctly to both structures, but all tetrapeptide and larger fragments docked correctly only to the complexed Fab, even when torsional flexibility was added to the ligand. However, only tetrapeptide and larger fragments showed significantly more favorable energies when docked to the complexed Fab coordinates than when docked to either the free Fab or a non-specific site remote from the combining site. Comparison of the free and complexed B13I2 structures revealed that atoms within 5 A of Val-Pro-His showed little movement upon peptide binding, but atoms within 5 A of the other four epitope residues showed greater movements. These results computationally distinguished recognition and binding processes with practical implications for drug design strategies. Overall, this new fragment docking approach establishes distinct roles for the "lock-and-key" (recognition) and the "handshake" (binding) paradigms in antibody-antigen interaction, suggests an incremental approach to incorporating flexibility in computational docking, and identifies critical regions within receptor binding sites for ligand recognition.

Site-directed mutagenesis of a catalytic antibody: an arginine and a histidine residue play key roles

Individual residues important for ligand binding and catalytic activity were identified by computer modeling and investigated by site-directed mutagenesis for catalytic antibody 43C9, which accelerates amide hydrolysis by a factor of 10(6). On the basis of a computer model, Tyr L32, His L91, Arg L96, His H35, and Tyr H95 were chosen for replacement by site-directed mutagenesis. To facilitate these studies, an expression system was developed in which properly folded 43C9 single-chain antibody was secreted from an engineered Escherichia coli host. Substitution of His L91 by Gln produced a mutant with no catalytic activity, but whose affinities for ligands were nearly the same as those of the wild-type, identifying His L91 as the nucleophile that forms the acyl intermediate implicated by previous kinetic studies. Arg L96 is also critical for catalytic activity and appears to function as a oxyanion hole for the tetrahedral transition states. Two substitutions for His H35 resulted in mutant proteins with no catalytic activity as well as altered affinities for ligands, indicating an important structural role for this residue. Substitutions for Tyr L32 and Tyr H95 were made in an attempt to improve the catalytic efficiency of 43C9. The results of these mutations allow us to propose a mechanism for 43C9-catalyzed hydrolysis: Substrate binding to 43C9 orients the scissile carbonyl group adjacent to both the His L91 and Arg L96 side chains. The imidazole of His L91 acts as a nucleophile, forming an acyl-antibody intermediate that breaks down by hydroxide attack to afford the products and regenerate the catalyst.

Catalytic antibody model and mutagenesis implicate arginine in transition-state stabilization

To probe the mechanism of the catalytic antibody NPN43C9, we have constructed a three-dimensional model of the NPN43C9 variable region using our antibody structural database (ASD), which takes maximal advantage of immunoglobulin sequence and structural information. The ASD contains separately superimposed variable light and variable heavy chains, which reveal not only conserved backbone structure, but also structurally conserved side-chain conformations. The NPN43C9 model revealed that the guanidinium group of light chain Arg L96 was positioned at the bottom of the antigen-binding site and formed a salt bridge with the antigen's phosphonamidate group, which mimics the negatively charged, tetrahedral transition states in the hydrolysis reaction. Thus, the model predicts both binding and catalytic functions for Arg L96, which previously had not been implicated in either. First, Arg L96 should enhance antigen binding by electrostatically complementing the negative charge of the antigen, which is buried upon complex formation. Second, Arg L96 should promote catalysis by electrostatically stabilizing the negatively charged transition states formed during catalysis. These hypotheses were tested experimentally by design and characterization of the R-L96-Q mutant, in which Arg L96 was replaced with Gln by site-directed mutagenesis. As predicted, antigen binding in the R-L96-Q mutant was decreased relative to that in the parent NPN43C9 antibody, but binding of antigen fragments lacking the phosphonamidate group was retained. In addition, the R-L96-Q mutant had no detectable esterase activity. Thus, the computational model and experimental results together suggest a mechanism by which the catalytic antibody NPN43C9 stabilizes high-energy transition states during catalysis.

Active conformation of the pyrokinin/PBAN neuropeptide family for pheromone biosynthesis in the silkworm

Members of the pyrokinin/pheromone biosynthesis activating neuropeptide family elicit pheromonotropic activity in at least two species of moths. We report that in the silkworm (Bombyx mori) the conformationally constrained octapeptide analog cyclo[Asn-Thr-Ser-Phe-Thr-Pro-Arg-Leu] retains 10% of the pheromonotropic activity of naturally occurring Bom-PBAN-I, a 33 amino acid peptide. Previous data from CD, NMR, and molecular dynamics analyses indicate a type I beta-turn conformation for active core residues Thr-Pro-Arg-Leu in the cyclic analog. The rigidity of the well-defined backbone structure of this cyclic pyrokinin/PBAN analog suggests that it represents the conformation necessary to interact with the pheromonotropic receptor site in the silkworm.

Protein metal-binding sites

Metal ions have a role in a variety of important functions in proteins including protein folding, assembly, stability, conformational change, and catalysis. The presence or absence of a given metal ion is crucial to the conformation or activity of over one third of all proteins. Recent developments have been made in the understanding and design of metal-binding sites in proteins, an important and rapidly advancing area of protein engineering.

Generation and analysis of random point mutations in an antibody CDR2 sequence: many mutated antibodies lose their ability to bind antigen

We have investigated the impact of mutations on the binding functions of the phosphocholine (PC)-specific T15 antibody in the absence of antigen selection pressure. The H chain complementarity determining region 2 (CDR2) sequence of T15 antibody was saturated with point mutations by in vitro random mutagenesis. From the mutant library, 289 clones were screened by direct DNA sequencing. The point mutations generated by this method were randomly distributed throughout the CDR2 region and included all kinds of substitutions. 46 unique mutant antibodies, containing one to four point mutations each, were expressed in SP2/0 myeloma cells. Functional analysis on these antibodies has provided insights into several aspects of somatic mutation. (a) The majority (26/46) of mutant antibodies either lost (20/46) or had reduced (6/46) ability to bind PC-protein conjugates or R36a, a PC-expressing strain of Streptococcus pneumoniae. In contrast, none of the mutant antibodies displayed increased binding for these PC antigens. Taken together with calculations of destructive mutations elsewhere in the V region, the data suggest that somatic mutation may cause extensive wastage among B cells during clonal expansion after antigen stimulation. (b) The frequency of binding-loss mutants increased sharply when a second mutation was introduced into the CDR2 sequence; it appears that, in some cases, two or more mutations are needed to destroy binding. (c) The mutant antibodies were tested for their reactivity to 11 non-PC antigens as well as to three PC analogues. None of the mutants gained new reactivity or changed their ability to discriminate structural analogues, supporting the notion that the major role of somatic mutation is to increase or decrease affinity rather than to create new specificities. (d) Mutations in at least five different positions in CDR2 were deleterious, suggesting that these residues may be essential for antigen binding. Three of these positions are novel in that they had not been identified to be important for binding PC by previous crystallographic analysis. (e) Introduction of mutations into two highly conserved residues in CDR2 did not alter the overall conformation of the V region as judged by antiidiotypic analysis, and, in some cases, did not affect the antigen binding function. The results thus indicate that even nonconservative substitutions of invariant residues need not be deleterious, suggesting that their conservation may be due to reasons other than maintaining antibody structure or specificity.

Metal-binding sites in proteins

A dramatic increase in the number of solved metalloprotein structures and recent breakthroughs in structural analysis have provided a sufficiently detailed understanding of the structural chemistry of some metal-binding sites to allow successful design. As a result, metal-binding site design is now one of the most powerful and promising approaches for influencing protein folding, assembly, stability and catalysis.