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Supplemental Materials for
the Video, “Tap into Prevention: Drinking
Water Information for Health Care Providers”
EPA 816-K-04-004, August 2004
Contents
Objectives
After watching this video, you will be able to:
- Name four health problems related to contaminants in drinking water
- Identify the types of patients most sensitive to each health problem
- Describe how contaminants can enter drinking water supplies
- Identify the treatment methods that remove the contaminants
- List clinical findings that should prompt reporting suspicion of a
waterborne disease to the local health department
- Describe how patients can learn about the quality of their drinking
water
- Describe the role of health care providers in a public health network
that identifies and responds to waterborne illness
- List resources for further information on drinking water and health
Key Concepts
The following information represents some contaminants to which certain
patients may be particularly sensitive.
Cryptosporidium parvum. Cryptosporidium
parvum is a pathogen found in human and animal fecal waste. It can
enter rivers, lakes, and streams and, rarely, ground water that contribute
to drinking water supplies. Because of its small size and composition,
it is resistant to typical filtration and disinfection methods 00 though
EPA has tightened its standards in recent years requiring public water
systems specifically to address this contaminant.
- Exposure to Cryptosporidium parvum in drinking water may
cause gastrointestinal problems, such as diarrhea, vomiting, and cramps.
Patients whose immune systems are weakened by AIDS, chemotherapy, a
recent transplant or other reasons are most vulnerable. Diarrhea and
vomiting may cause infants and the frail elderly to become dehydrated
more quickly. In most healthy adults and children, the problems are
temporary. Other, more common routes of exposure to this pathogen are
food, unsanitary diaper-changing practices, person-to-person contact,
and swimming in contaminated water.
- Suggested interventions: Sample stools more frequently. Include questions
on water sources for patients with diarrhea. Those with questionable
water sources require further investigation. Most standard ova and parasite
cultures do not automatically test for Cryptosporidium. Be sure to specifically
request an acid-fast fluorescent test.
Escherichia coli or E. coli. E. coli is
a type of fecal coliform bacteria commonly found in the intestines of
animals or humans. The presence of E. coli in water is a strong
indication of recent sewage or animal waste contamination. Sewage may
contain many types of disease-causing organisms. Although most strains
of E. coli are harmless and live in the intestines of healthy
humans and animals, a particular strain, E. coli O157:H7, produces
a powerful toxin and can cause severe illness.
- Most infections of E. coli O157:H7 are believed to have come
from eating undercooked ground beef. However, some have been waterborne,
and people have become sick after drinking contaminated water.
- Infection by E. coli O157:H7 is characterized by severe bloody
diarrhea and abdominal cramps, although sometimes the infection causes
non-bloody diarrhea, often with no fever. In some people, particularly
children under 5 years of age and the elderly, the infection can also
cause a life-threatening complication called hemolytic uremic syndrome,
in which the red blood cells are destroyed and the kidneys fail. Hemolytic
uremic syndrome is usually treated in an intensive care unit, and blood
transfusions and kidney dialysis are often required.
- Suggested interventions: Encourage patients (or their parents) to
have household well water tested annually for nitrates and bacteria
by a state-certified laboratory. If a patient's well tests positive
for E. coli, people in the household should not drink the water
without boiling the water for at least one minute at a rolling boil
- longer if they live at high altitudes. The well may also be disinfected
according to procedures recommended by the local health department.
Water must be monitored periodically after disinfection to make certain
the problem does not recur. If contamination is a recurring problem,
patients should investigate the feasibility of drilling a new well or
installing a point-of-entry disinfection unit using chlorine, ultraviolet
light, or ozone.
Disinfectants and Disinfection Byproducts (DBPs). Disinfectants,
while effective in controlling many microorganisms, react with matter
in water to form DBPs. Unchlorinated private well water is unlikely to
contain any DBPs.
- While health effects from exposure to disinfectants and DBPs vary
by contaminant, some epidemiological studies have shown a link between
bladder, rectal, and colon cancers and DBP exposure. Additionally, human
epidemiological studies report an association between chlorinated drinking
water and reproductive and developmental endpoints such as spontaneous
abortion, neural tube defects, pre-term delivery, intrauterine growth
retardation, and low birth weight. In August 2003, EPA proposed measures
beyond those already required for public water systems.
- Suggested interventions: Drinking plenty of water from a safe source
during pregnancy is important. If your patients' public water system
has notified customers of a DBP violation, follow instructions from
the public water system. For example, your patients might want to consider
alternatives to tap water during pregnancy.
Lead. Paint chips and dust from lead paint in old buildings
are the primary routes of children's exposure to lead, but EPA estimates
that up to 20 percent of a person's background exposure may be due to
lead in drinking water - and the percentage is higher for infants drinking
formula mixed with contaminated drinking water. Lead may be present in
drinking water because of corrosion of household plumbing systems; erosion
of natural deposits. In some communities, lead service lines can also
contribute to high levels of lead in drinking water.
- In infants and young children, continuous exposure to high
levels of lead may result in delays in physical or mental development,
deficits in attention span, and learning disabilities.
- For adults, such exposure may result in kidney problems or high blood
pressure.
- Suggested interventions: Look for symptoms of lead poisoning in children,
and test infants' blood lead levels. If a child's blood lead level is
high, consider lead in tap water as a possible factor, in addition to
lead paint exposure. Encourage patients to have drinking water tested
for lead in homes, schools, and day care centers by a state-certified
laboratory. Encourage local schools and day care centers to test their
drinking water outlets for lead.
- Use only cold water for drinking, cooking, and especially making baby
formula. It's important to consider that foods that absorb all of the
water in the pot, such as rice and dried beans, will also absorb all
of the lead that is in the cooking water. Soups made or mixed with water
will also contain any lead that's in the water. Foods cooked in water
and then drained, such as pasta, meat, or vegetables, also absorb some
lead from the water.
- If lead levels in drinking water are high, consider alternatives to
using boiled tap water in baby formula.
- Information and brochures are available from the National Lead Information
Center, (800) 424-LEAD [5323], www.epa.gov/lead/pubs/nlic.htm.
Nitrates and Nitrites. Nitrates may run off or percolate
into water sources from excessive fertilizer use and animal waste; leaching
from improperly constructed or maintained tanks, cesspools, sewage; or
erosion of natural deposits.
- Exposure to nitrates in drinking water at levels above the drinking
water standard may result in methemoglobinemia, or "blue
baby syndrome," in infants under six months. Blue baby
syndrome is life-threatening without immediate medical attention. Infants
most likely to get methemoglobinemia are those who are already sick
and consume food that is high in nitrates, such as spinach, broccoli
and cured meats, and drink formula mixed with water that is high in
nitrates.
- Possible interventions: Encourage patients to have household well
water tested annually for nitrates and bacteria by a state-certified
laboratory, especially those caring for infants and expectant parents
and grandparents. If water has high nitrate levels, consider alternatives
to using bottled tap water in baby formula. Boiling water only increases
nitrate concentrations.
Drinking Water Security. Events of September 11, 2001,
have brought into focus the possibility of intentional contamination of
drinking water and wastewater infrastructure. Doctors, nurses, and others
in primary care would likely be the first to observe unusual illness patterns
or disease trends resulting from intentional biological or chemical contamination.
"Recognizing Waterborne Disease and the Health Effects of Water
Pollution: A Physician On-line Reference Guide," by Patricia L. Meinhardt,
MD, MPH, MA, includes a section, "Physician Preparedness for Acts
of Water Terrorism." It is available at WaterHealthConnection.org.
Recognize, Report, and Prevent Waterborne Illness
- Report suspicion of waterborne illness to your local health department.
- Take an environmental health history that includes, "What is
the source of drinking water?"
- Familiarize yourself with your patients' water supply. Annual water
quality reports are a good first source of information on local public
water systems. Household well owners are responsible for making sure
their wells are tested regularly and maintained properly. A free booklet,
"Drinking Water from Household Wells," is available at www.epa.gov/safewater/privatewells/booklet/index.html.
Drinking Water Resources
EPA Office of Ground Water and Drinking Water
Together with states, tribes, and our many partners, the Office of Ground
Water and Drinking Water protects public health by ensuring safe drinking
water and protecting ground water. EPA's Safe Drinking Water Hotline provides
information about drinking water and ground water protection programs
authorized under the Safe Drinking Water Act. (800) 426-4791
www.epa.gov/safewater
CDC Division of Parasitic Diseases
The mission of the division is to prevent and control parasitic diseases
in the United States and throughout the world and to increase survival
of children in developing countries, through surveillance and by conducting
laboratory and epidemiological research.
www.cdc.gov/ncidod/dpd/healthywater 
Home Water Testing
Your state Certification Officer can provide a list of laboratories
certified to test for contaminants in drinking water.
www.epa.gov/safewater/faq/sco.html
Household Wells
Home*A*Syst
Provides information to help farmers and rural residents assess pollution
risks and develop management plans to meet their unique needs.
www.wisc.edu/farmasyst
Wellcare® Hotline
(888) 395-1033
Through wellcare®, the Water Systems Council provides rural well
owners, other technical assistance providers, water system operators,
and community leaders important information and training on how to properly
design, operate and manage well-based systems.
www.watersystemscouncil.org/wellcare
DrinkWell TM Well Water Testing
Underwriters Laboratories' well testing service also has a nurse call
center and provides sources of information. For questions regarding
ordering, sample collection and shipping, call 888-503-5544.
www.uldrinkwell.com
National Ground Water Association
This National Ground Water Association's Wellowner web site offers a
variety of information relating to ground water and private water well
systems.
www.wellowner.org
Home Water Treatment Units
Water Quality Association
The Water Quality Association is a not-for-profit international trade
association representing the household, commercial, industrial, and
small community water treatment industry.
www.wqa.org
NSF International
NSF International's Home Water Treatment Devises web page includes information
on selecting and using water treatment devices.
www.nsfconsumer.org/water/dw_treatment.asp
Underwriters Laboratories
Underwriters Laboratories tests and certifies home water treatment units
to ensure they meet national standards.
www.ul.com/water
Bottled Water
International Bottled Water Association
This trade association requires members to adhere to its model code,
in addition to meeting federal requirements for bottled water.
www.bottledwater.org
NSF International
NSF International tests bottled water products for compliance with federal
guidelines and lists bottled water companies certified through its voluntary
certification program.
www.nsfconsumer.org/water/bottled_water.asp
Protecting Drinking Water Sources
EPA's Source Water Protection Program
EPA has information on preventing contamination of streams, rivers,
lakes and underground aquifers that supply private wells and public
drinking water.
www.epa.gov/safewater/protect.html
Groundwater Foundation
The Groundwater Foundation educates and motivates people to care for
and about ground water through water festivals and other activities.
Its Groundwater Guardian program encourages communities to begin and
enhance ground water awareness and protection activities.
www.groundwater.org
American Ground Water Trust
This educational organization protects ground water and promotes resource
sustainability; communicates the value of ground water; showcases science
and technology solutions; increases awareness; and facilitates stakeholder
participation in water resource decisions.
www.agwt.org
Ground Water Protection Council
The Ground Water Protection Council is a national association of state
ground water and underground injection control agencies whose mission
is to promote the protection and conservation of ground water resources
for all beneficial uses, recognizing ground water as a critical component
of the ecosystem.
www.gwpc.org
National Ground Water Association
The National Ground Water Association's mission is to enhance the skills
and credibility of all ground water professionals, develop and exchange
industry knowledge and promote the ground water industry and understanding
of ground water resources.
www.ngwa.org
Water Systems Council
The Water Systems Council is a national non-profit organization, dedicated
to promoting the wider use of wells as modern and affordable safe drinking
water systems and to protect ground water resources.
www.watersystemscouncil.org
Additional Resources for Health
Professionals
This list is not meant to be exhaustive, but includes opportunities for
further continuing education on drinking water and resources on environmental
health.
"Recognizing Waterborne Disease and the Health Effects of Water
Pollution," and online reference guide; up to 22 Continuing Medical
Education credits and continuing education credits for other professions
are sponsored by the American College of Preventive Medicine. Bu Patricia
Meinhardt, MD, MPH, MA. Includes a repository of information on how to
detect biological and chemical weapons exposure and respond appropriately.
www.WaterHealthConnection.org
"Waterborne Disease and Water Pollution: What Every Physician in
Your Community Needs to Know." This American College of Preventive
Medicine Institute contains 10 presentations by various physicians and
water professionals in streaming video and audio. Speakers provide a clinical
overview of diagnosis and management of waterborne disease and health
effects of water pollution, as well as strategies for risk communication
to discuss these environmental health issues with patients. The sessions
also address challenges facing the water utility community, tasked with
providing safe drinking water in America. www.acpm.org/ehealth/waterborne.htm
Drinking Water and Disease: What Every Health Care Provider Should Know,
Physicians for Social Responsibility. www.envirohealthaction.org/upload_files/dwprimer.pdf
"Environmental Health and Nursing," a developing educational
series designed to assist nurses integrating environmental health knowledge
and skills in professional practice through distance learning. CEU and
graduate credits available.
University of Minnesota School of Public Health, http://mclph.jawshotel.umn.edu/pubh7201
University of Maryland School of Nursing EnviRN Website: A Virtual Resource
for Environmental Health and Nursing, www.envirn.umaryland.edu.
EnviRN's gateway to an array or resources, including multimedia content:
envirn.umaryland.edu/resources/resources.htm
Environmental Health and Nursing Practice, by Barbara Sattler,
RN, DrPH, and Jane Lipscomb, RN, PhD, FAAN, Editors, www.springerpub.com/store/page4282_6.html
National Environmental Education and Training Foundation Health Publications
Includes links to information for health care providers on pesticides,
ranging from national strategies to medical and nursing practice guidelines.
www.neetf.org/Health/publications.sthm
Acknowledgments
Co-authors:
John Balbus, MD, MPH, Director, Environmental Health Program, Environmental
Defense, Washington, DC; Founding Director, George Washington University
Medical School Center for Risk Science and Public Health, Washington,
DC
Vince Clews, Screenwriter, Baltimore, MD
Sherri Umansky, Environmental Protection Specialist, Office of Ground
Water and Drinking Water, U.S. Environmental Protection Agency, Washington,
DC
Narrators:
John Balbus, MD, MPH
Paul Anthony, Actor, Chevy Chase, MD
Featured Experts:
Milwaukee
Paul Bierdrzycki, Manager of Disease Control, City
of Milwaukee Health Department
*Kathleen Blair, RN, Epidemiologist, City of Milwaukee Health Department
Mary Busalacchi, HIV Nurse Clinician, Milwaukee
Lon Couillard, Water Quality Manager, Milwaukee Water Works
Ian Gilson, MD, Internist, Milwaukee
Karen Sue Kehl, PhD, Associate Professor and Section Director, Microbiology,
Medical College of Wisconsin; Technical Director of Microbiology, Children's
Hospital of Wisconsin
Paul Nannis, Vice President, Department of Government and Community
Relations, Aurora Health Care; formerly City of Milwaukee Health Commissioner
Mary Rotar, RN, Infection Control Coordinator for Children's Health
Care System and formerly for West Allis Memorial Hospital, Milwaukee
Thomas A. Taft, MD, Infectious Disease Specialist, Hospital Epidemiologist,
and Chair of Infection Control at West Allis Memorial Hospital; Assistant
Clinical Professor, St. Joseph's Hospital, Milwaukee
* Case Study Coordinator
Philadelphia
Carla Campbell, MD, Medical Director, Lead Poisoning
and Toxicology Clinic, Children's Hospital of Philadelphia; Pediatric
Consultant, Philadelphia Department of Health
*Lisa Donahue, Environmental Scientist, EPA Region III, Philadelphia
Karen Johnson, Chief, Safe Drinking Water Act Branch, Office of Compliance
and Enforcement, EPA Region III, Philadelphia
Richard Tobin, Program Director, Philadelphia Childhood Lead Poisoning
Prevention Program
* Case Study Coordinator
Minnesota
Terri Helland, RN, Public Health Nurse, Brown County Public Health
Anita Hoffmann, Director, Brown County Public Health
*Bonnie Holz, Public Health Preparedness Coordinator, Minnesota Department
of Health; formerly Environmental Health Director for Brown, Nicollet
and Cottonwood Counties
Kevin Kuehner, Water Quality Specialist, Brown Nicollet Cottonwood
Water Quality Board
* Case Study Coordinator
Physician, Nurse, and Health Educator Reviewers
The following people helped ensure the activity met criteria required
for a continuing education activity within their professions.
Brenda Afzal, RN, BSN, MS, Project Manager, University of Maryland
School of Nursing, Environmental Health Education Center
John M. Balbus, MD, MPH
Diane Drew, RN, Senior Health Education Specialist, CDC
Cathey E. Falvo, MD, MPH, Professor of Public Health Practice, Clinical
Associate Professor of Pediatrics, New York Medical College
Sharon Hall, RN, Public Health Advisor, Acting Branch Chief, Learner
Support, CDC
Barbara Sattler, RN, DrPH, Associate Professor and Director, Environmental
Health Education Center, University of Maryland School of Nursing
Lauren Swirsky, MPH, CHES, Senior Health Education Specialist, Division
of Health Education, ATSDR
Dianyi Yu, MD, PhD, Medical Officer, CDC
Special Thanks:
In addition to workplaces of the experts interviewed, the following organizations
have contributed video footage, still images, or filming locations to
this production:
Fairmount Water Works Interpretive Center, Philadelphia Water Department
Georgetown Aqueduct in Washington, DC, operated by the U.S. Army Corps
of Engineers
School District of Philadelphia
Mulberry Child Care & Preschool, Philadelphia
CH Diagnostic & Consulting Services, Inc., Loveland, Colorado
U.S. Department of Agriculture, Soil Conservation Service
Thank you to all those who participated in pilot testing, and to staff
at EPA, CDC, and ATSDR, too numerous to list, who reviewed multiple drafts
and provided valuable critiques and advice.
Finally, thank you to all those involved, on- and off-camera, in the production
of this video. The Milwaukee segment was filmed the week of September
11, 2001, and the Philadelphia and Minnesota segments were filmed just
a few weeks later. The hospitality and commitment of our hosts, and the
diligence, support, and professionalism of the DC-based crew, made this
production possible and will not be forgotten.
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