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Waterborne disease outbreaks (WBDO) associated with tap water consumption are probably underestimated in France.


In order to improve their detection, Santé publique France launched a surveillance system in 2019, based on the periodical analysis of health insurance data for medicalised acute gastroenteritis (mAGE).


Spatio-temporal cluster detection methods were applied to mAGE cases to prioritise clusters for further investigation. These investigations determined the plausibility that infection is of waterborne origin and the strength of association.


Between January 2010 and December 2019, 3,323 priority clusters were detected (53,878 excess mAGE cases). They involved 3,717 drinking water supply zones (WSZ), 15.4% of all French WSZ. One third of these WSZ (33.4%; n = 1,242 WSZ) were linked to repeated clusters. Moreover, our system detected 79% of WBDO voluntarily notified to health authorities.


Environmental investigations of detected clusters are necessary to determine the plausibility that infection is of waterborne origin. Consequently, they contribute to identifying which WSZ are linked to clusters and for which specific actions are needed to avoid future outbreaks. The surveillance system incorporates three priority elements: linking environmental investigations with water safety plan management, promoting the systematic use of rainfall data to assess waterborne origin, and focusing on repeat clusters. In the absence of an alternative clear hypothesis, the occurrence of a mAGE cluster in a territory completely matching a distribution zone indicates a high plausibility of water origin.


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