Abstract
From July to October 2001, 215 cases of aseptic meningitis occurred among the inhabitants of the German city of Kassel and neighbouring counties. A matched case-control study identified bathing in a public, nature-like pond during the beginning of the outbreak as a risk factor for disease [matched odds ratio (mOR) 44.8, 95% confidence interval (CI) 3.9-515.6]. Among bathers, patients with meningitis spent more time in the water (mOR 18.8, 95% CI 2.0-174.1) and swallowed water more frequently (mOR = 7.3, 95% CI 0.7-81.8). Of 30 cerebrospinal fluid samples tested, echovirus 30 was cultured from 16, and echovirus 13 from seven. An echovirus 30 sequence obtained from one pond water sample showed a 99% nucleotide and 100% amino-acid homology with patient isolates. This outbreak demonstrates the potential of nature-like swimming ponds to cause widespread community infection with substantial public health impact.