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Recommendations
Resulting from a Meeting held November 2-4, 1999
Baltimore, Maryland
The National Drinking Water Advisory Council (NDWAC) met at the Tremont
Plaza Hotel, Baltimore, Maryland, November 2-4, 1999. The main focus of
the meeting was alternative drinking water sources, i.e., bottled water
and Point-of-Use/Point-of-Entry (POU/POE) devices. The Council also received
the final reports of the Right-to-Know and Health Care Providers Outreach
and Education Working Groups. After hearing presentations from the Food
and Drug Administration, International Bottled Water Association, NSF
International and the Water Quality Association, the Council formulated
recommendations reflecting their thoughts and concerns regarding bottled
water and point-of-use/point-of-entry issues. Recommendations are also
being forwarded that complete the work of two of NDWAC's Working Groups.
Finally, a continuing concern and need for coordinated action between
EPA water programs and the state departments of health to address the
microbiological contribution to watersheds from a variety of sources,
resulted in a recommendation.
BOTTLED WATER
Clean and safe drinking water is essential to every American. Assuring
high quality drinking water in this country depends upon setting strict
standards, vigilantly monitoring current operations, and improving public
awareness.
The Safe Drinking Water Act sets these high standards for treatment,
testing, and reporting for drinking water for public water systems. However,
a large and ever-increasing portion of the American population are using
bottled water to meet their daily drinking water needs. The EPA, in special
circumstances, has recommended the consumption of bottled water (in lieu
of tap water) when there may be unacceptable risks associated with the
consumption of public drinking water. The National Drinking Water Advisory
Council (NDWAC) is concerned that quality assurance of bottled water -
through testing and reporting - may not be adequate to protect public
health. Our concerns include, but our not limited to:
- Labeling. We believe that some bottlers do not accurately identify
the source and treatment of the water. Additionally, some bottlers may
claim that water is free of protozoa when it is unlikely to be accurate
in all cases, leaving immune compromised people in an "at-risk" situation;
- Shelf life. Bottled waters, unlike most processed food products,
are not required to publicize a shelf life, yet it is likely that their
quality diminishes over time. Many water bottlers do explicitly state
an expiration date for their product, indicating that the issue of shelf
life is a legitimate one. Related to this concern, questions have been
raised about the safety of some packaging when bottled waters are not
consumed within a defined period.
- Tracking of distribution of bottled waters. The labeling of
bottled water often does not track sales in a way that would permit
location and identification of lots that may (retrospectively) be identified
as contaminated.
- Monitoring of compliance with public health standards. Public
health safety is in part assured by frequent testing of public drinking
water, and the reporting and monitoring of this data by governmental
authorities. Based upon FDA and industry representations made to NDWAC,
the harmonization between public drinking water and bottled waters of
testing requirements, may be beneficial. For instance, there is no requirement
that bottlers test their water for some contaminants on a basis more
frequently than yearly. We are aware that bottlers are only infrequently
inspected by the FDA, and aware that specific testing for Cryptosporidium
with advanced methods (such as EPA Method 1623) is not routinely performed.
Lastly, the FDA does not currently have a centralized database of bottled
water compliance, nor actively monitors State information.
- Consumer Right-to-Know. Consumers have a right to know what
is in a product, and should have a clear and reasonable way for obtaining
information about a product that may be deficient, or inappropriate
given their health concerns. Consumers in the United States are provided
with detailed information about their public drinking water supply on
an annual basis. In contrast, the current process for meeting consumer
information needs regarding bottled waters is, in our opinion, deficient
and does not meet consumer needs.
- Intrastate Bottlers. It appears that there is almost no oversight
or monitoring of bottlers whose operations fall entirely within a state
that does not have a specific state-based bottled water monitoring program.
Moreover, it appears that many states have only minimally staffed oversight
and monitoring programs for bottled water.
- International Bottlers. It appears FDA does not do any inspections
of International bottlers.
Recommendations
Therefore, NDWAC recommends to the Administrator that EPA work closely
with FDA to assure that bottled water quality meet public health standards
through testing, monitoring, and reporting procedures that are at least
as stringent as the requirements for public water supplies. NDWAC further
recommends that coordination might best be accomplished through a joint
EPA/FDA stakeholder working group or a Memorandum of Understanding to
develop the specifics of a quality assurance and reporting program.
POE/POU DEVICES
The use of centralized water treatment is becoming an increasingly costly
option for some small water systems as they struggle to provide water
that meets national primary drinking water regulations (NPDWR). The use
of point of entry (POE) and point of use(POU) devices may be a solution
for certain small water systems in meeting the NPDWR. The identification
of cost effective POE/POU devices is a critical issue that needs to be
addressed.
Recommendations:
The NDWAC recommends that EPA continue to undertake and support research
that will identify affordable POE/POU devices. The focus of this research
should not be limited to chemical contaminants, but should include research
on POE devices that can be used to comply with standards for microbial
contaminants such as the surface water treatment rule.
The use of POE/POU devices may also have application for use by certain
sub-populations that could be susceptible to contaminants, particularly
microbial, in drinking water that is meeting NPDWR. NDWAC recommends that
EPA should evaluate the viability of using POE/POU devices to protect
these sub-populations. This evaluation should be carried out under the
assumption that the operation, maintenance and monitoring of these devices
is under the purview of the public water system.
NDWAC recommends that EPA should clearly differentiate between POE/POU
devices which are "add-ons" to existing treatment to meet NPDWR and those
which are used solely to meet NPDWR.
MICROBIOLOGICAL CONTRIBUTIONS TO WATERSHEDS
Recommendation:
NDWAC recommends that EPA plan and conduct a national forum/workshop
which includes internal agency staff from each region and state involved
in NPDES permitting/ water quality standards (and beneficial uses development)
and Safe Drinking Water Act implementation, along with Department of Health
Services (DOHS) state representatives. The purpose of this forum is to
focus attention on the microbiological contribution to watersheds from
wastewater discharges, reclamation projects and non-point permitted sources
and their impact on drinking water quality. Disinfection processes, regulatory
discharge standards, monitoring requirements, dilution criteria, discharge
siting, and mass emission limits should be reviewed for their effectiveness
and applicability to not only control traditional pathogens and indicators,
but to emerging and/or currently proposed for regulation pathogens, such
as, Giardia and Cryptosporidium. Results of this forum should be published
and submitted to EPA and State Health staff as a guidance document.
CONSOLIDATION OF WATER SYSTEMS
Following the presentation of a status report from the NDWAC Small Systems
Implementation Working Group, the Council offered the following recommendation.
This working group will wrap up its mission within a few months, sending
its final report to NDWAC for consideration.
Recommendation:
NDWAC recommends that EPA investigate a federal economic incentive program
aimed at consolidation of water systems through creation of rates of return,
buy out subsidies or rate payer relief that encourages utilities to consolidate
through a market based approach.
REPORT OF THE RIGHT-TO-KNOW WORKING GROUP
After completing its mission, the Right-to-Know Working Group submitted
its final report to the Council. The following recommendations are forwarded
to the Agency:
RECOMMENDATIONS
Evaluate Consumer Confidence Reports
1. NDWAC recommends that
EPA evaluate Consumer Confidence Reports on their effectiveness as a communication
tool.
Coordinate Development of Materials and Outreach to Health Care
Providers
2. NDWAC recommends that
the EPA work with other federal agencies (to include
the Departments of Health and Human Services' Agency for Toxic Substances
and Disease Registry, Centers for Disease Control, Food and Drug Administration;
and the Departments of Education, Transportation, Agriculture, Labor,
Interior, and Defense) to encourage integration of environmental
health into Health Care Provider professionals' practice in the
areas of practice, education, and research.
3. NDWAC recommends that EPA coordinate its internal efforts
(such as in the areas of water, pesticides, and children's health) to
educate and provide outreach to the Primary Health Care Provider (HCP)
community - particularly nurses and physicians. It is recommended
that, in consultation with HCP professionals, the EPA develop
a coordinated approach to communicating environmental health information
to the Health Care Providers. Further, it is recommended that the Agency
develop a guiding principle regarding the Agency's approach
to HCPs. This principle would include guidance on determining
Agency priorities, messages, and materials.
Continue good progress on development and distribution of messages
and materials to support Consumer Confidence Reports, as recommended by
NDWAC at its November, 1998, and May, 1999 meetings.
4. NDWAC commends the
EPA on its progress in developing messages and materials to alert many
audiences to the fact that Consumer Confidence Reports are coming, to
help them to read and understand the reports, and to assure that they
know where to go for further information or to get involved. NDWAC
recommends that EPA complete the products which are in development,
as recommended by the Right-to-Know Working Group and that EPA
expedite distribution of these materials via the web site, print
copy distribution, and through conferences and meetings.
Attachment A to National Drinking Water Advisory Council recommendations:
REPORT OF THE HEALTH CARE PROVIDER OUTREACH AND EDUCATION
WORKING GROUP
This following recommendation completes the mission of the Health Care
Provider Outreach and Education Working Group:
RECOMMENDATION:
The National Drinking Water Advisory Council forwards to the Administrator
of EPA the attached "Strategic Assessment and Recommendations." This strategy
will help shape the Agency's efforts on this topic in cooperation with
other government and non-government partners. The Council considers this
report the principal product of the Working Group, meeting all the goals
of its Mission Statement. It is the sense of the NDWAC that the Agency
should brief them on the implementation of this strategy on an annual
basis.
Attachment:
"Strategic Assessment and Recommendations"
Attachment A:
National Drinking Water Advisory Council
Strategic Assessment and Recommendations
Overview of Findings
The National Drinking Water Advisory Council (NDWAC) serves an advisory
role to the Administrator of the U.S. Environmental Protection Agency
(EPA) on the implementation of the Safe Drinking Water Act (SDWA). At
its Spring 1998 meeting, NDWAC discussed the strategic need to forge better
links with the community of doctors, nurses, and other health care providers
on drinking water concerns. NDWAC called for the establishment of a Working
Group on this topic, not to make specific regulatory recommendations,
but to examine from a broad strategic perspective whether the health care
provider community needs to become better educated on drinking water issues,
and how such an effort might be structured. The Health Care Provider Outreach
and Education Working Group deliberated on this matter from December 1998
through October 1999, and made several critical observations and recommendations,
including:
- Although the risk of waterborne disease due to contaminants in drinking
water is perceived to be far less a problem than in decades past, public
concern for the safety of their tap water remains a major issue. The
public has considerable trust in their doctors, nurses, and other health
care providers (HCPs), yet these professionals receive very little information
on drinking water. HCPs who see patients experiencing gastrointestinal
illness, for example, may not recognize that the illness could be from
contaminated drinking water. The correct diagnostic tests may not be
ordered, treatment might be inappropriate for the illness, and possible
waterborne disease outbreaks may be missed. Short and longer-term outreach
and education efforts to HCPs would help to remedy this problem.
- The first need is to better equip HCPs to answer general questions
that their patients may have on the overall safety of their drinking
water, or on particular risk-avoidance behavior they might take given
their personal health profile. The Working Group believes that Federal
efforts to meet this need can build upon those already underway; for
example relating to implementation of the Consumer Confidence Reports.
Information products should include those tailored to specific sub-populations
such as the immune-compromised and infants. Health effects and avoidance-behavior
language used in these products should be as clear, unambiguous, and
succinct as possible.
- The next need is to assure that practicing HCPs have the necessary
tools to recognize, report, and treat illness that might have been caused
by contaminants in drinking water. These tools could include, for example,
clinical practice guidelines which recognize drinking water as an environmental
health pathway, increased diagnostic testing by laboratories to differentiate
pathogens that might contaminate drinking water or cause illness, and
awareness of the importance of reporting outbreaks of diarrheal disease
or other conditions that could be caused by contaminated drinking water.
- The Working Group is particularly concerned about the very limited
attention that medical and nursing schools give to environmental health
issues generally. This is a recognized deficiency in training which
should be addressed by a broad partnership within EPA, as well as among
Federal agencies and professional organizations. Efforts to improve
basic curricular knowledge on drinking water will only succeed if they
are tackled from a multi-media perspective.
- The Working Group recognizes that HCPs are challenged with information
on an enormous range of medical and administrative matters. Outreach
and education products for widespread distribution need to be succinct
and clearly focused. Opportunities through, for example, the Internet
or professional networks, to direct interested HCPs (and their patients)
to a full range of studies and resources, are encouraged.
- The Working Group is enthusiastic over the longer term benefits of
collaboration between the HCP community and EPA on drinking water issues.
Apart from meeting the SDWA direction to EPA and CDC on HCP education
and training, such collaboration will support all aspects of regulatory
development, research and implementation.
- Several possible pilot projects have been outlined which can help
EPA and its partner organizations meet these near to longer-term needs.
2.0 Introduction
2.1 Background
Waterborne disease is no longer the major cause of severe illness and
death in the United States that it was in the 1800's, due to the introduction
of modern drinking water treatment technologies, and management and regulatory
programs for public water supplies. Despite these advances, a 1998 national
survey on drinking water(1) found that
there is still a significant concern and interest among the public regarding
the safety of their tap water. The survey also found that few adults seek
information from their doctors or other health care professionals, despite
the fact that they are probably the most trusted information source. This
mirrored the feeling among many drinking water experts that doctors, nurses,
and others in the health care provider (HCP) community may be unfamiliar
with how to recognize waterborne illness when it occurs, or be able to
fully respond to their patients who have questions on drinking water.
Patients may be particularly sensitized to drinking water this year due
to the SDWA-mandated release of Consumer Confidence Reports by water suppliers.
Media coverage of foodborne and waterborne disease outbreaks in 1998 and
1999 have also raised questions in the minds of the public.
The 1996 Amendments to the Safe Drinking Water Act (SDWA) continued to
stress the link between health and regulatory safeguards which served
as the underpinning of the Nation's drinking water laws for many decades.
The Amendments were debated and passed following the outbreak of cryptosporidiosis
in Milwaukee, the largest reported waterborne disease outbreak in U.S.
history. Many technical and policy specialists were also concerned over
the wide range in estimates regarding the extent of endemic (i.e. background
levels) of waterborne disease. The Milwaukee outbreak, media attention
to drinking water problems, and advertisements for bottled water and filters
were perceived as factors requiring a renewed federal focus on research,
education and outreach. One consequence of these conditions was the inclusion
of section 1458(d)(2) in SDWA, requiring that the U.S. Environmental Protection
Agency (EPA) and U.S. Centers for Disease Control and Prevention (CDC)
prepare a national estimate of waterborne disease, and an education and
outreach effort for the general public and health care providers. The
second of these provisions relates to the effort of this Working Group.
(2) TRAINING AND EDUCATION. The Director and Administrator
shall jointly establish a national health care provider training and public
education campaign to inform both the professional health care provider
community and the general public about waterborne disease and the symptoms
that may be caused by infectious agents, including microbial contaminants.
In developing such a campaign, they shall seek comment from interested
groups and individuals, including scientists, physicians, state and local
governments, environmental groups, public water systems, and vulnerable
populations.
EPA has been able to direct funds and work collaboratively with CDC on
the national estimate, and has made progress on education of the general
public with regards to drinking water issues. Uncertainty on what is needed
by the health care provider community, as well as funding constraints,
however, delayed attention to the health care provider education and outreach.
The National Drinking Water Advisory Council (NDWAC) felt that EPA (and
CDC) needed to approach health care provider outreach and education from
a strategic perspective, dealing with both short term and longer tem needs.
NDWAC requested at its Spring 1998 meeting that EPA assist in forming
a Working Group to advise NDWAC on its recommendations to EPA in this
regard. Mirroring the language of the statute, the Working Group was to
draw from a wide range of stakeholders.
2.2 The Health Care Provider Outreach and Education Working Group
The National Drinking Water Advisory Council serves an advisory role
to the Administrator of the U.S. Environmental Protection Agency (EPA)
on the implementation of the Safe Drinking Water Act (SDWA). At its Spring
1998 meeting, NDWAC discussed the need to forge better links with the
community of doctors, nurses, and other health care providers on drinking
water concerns. NDWAC called for the establishment of a Working Group
on this topic, not to make specific regulatory recommendations, but to
examine from a strategic perspective whether the health care provider
community needs to become better educated on drinking water issues, and
how such an effort might be structured.
EPA posted a notice in the Federal Register on May 18, 1998,
requesting nominations to four NDWAC working groups, including one on
"Waterborne Disease Education". In discussions with the nominees and several
sponsoring organizations, there was some concern with overlap on audience
and mission with another new NDWAC working group, that on Public Right-to-Know.
This led to a clarification of the first group to cover strategic recommendations
regarding "Health Care Provider Education and Outreach". Membership on
this Working Group was sought from a wide range in specialties and organizations
over the August through October, 1998 period. Representation was sought
from the local and State public health and drinking water fields, water
utilities and trade/professional associations, primary care physicians
and nurses, medical research, and health care communications. Invitations
to the final nominees to serve on the Working Group were sent from Cynthia
Dougherty, Director of the EPA Office of Ground Water and Drinking Water
in late October, 1998. The composition of the Working Group and its draft
Mission Statement were reviewed and ratified by the full NDWAC on November
17, 1998, at its meeting in Arlington, Virginia.
The Working Group held face-to-face meetings in Washington, DC on December
2-3, 1998 and June 1-2, 1999. Full group conference calls were held on
January 26, 1999, April 16, 1999, and September 27, 1999. Public notices
of all these full meetings were published in the Federal Register,
and meeting summaries are available from OGWDW. A number of sub-groups
worked on draft assessments, recommendations and interim products; these
groups communicated by E-mail and conference calls.
2.3 Working Group Roster and Mission
The current roster of Working Group members is included as Attachment
1. The final Mission Statement was approved by the Working Group at its
January 26, 1999 conference call to read:
Prepare an integrated strategy, for consideration by the
NDWAC, as to how the U.S. EPA and CDC should inform and educate health
care providers in their efforts to: 1) counsel persons about the quality
of their drinking water; and 2) recognize, report, treat, and prevent
adverse health effects that can be caused by infectious and non-infectious
agents that could be acquired from drinking water.
2.4 The Health Care Provider Community
One of the first issues faced by the Working Group was the definition
of the audience for the strategy. The U.S. Bureau of Labor estimated that
in June 1999, 9.98 million people were employed in the U.S. in the broadest
Health Services category(2). This includes,
for example, 1.87 million employees in offices and clinics of medical
doctors, and 1.75 million employees in nursing and personal health care
facilities. Apart from the size of the audience, the Working Group was
intimately familiar with the very wide range in expertise and specialization.
No one strategy, outreach product, or communications approach can be ideal
for all these groups. After several discussions, the Working Group suggested
several tiers:
Primary audience: general health care providers (e.g., internists,
nurses, general practitioners, nurse practitioners and physicians' assistants),
health advisors to sensitive subpopulations, and laboratory scientists.
Secondary audience: hospital and HMO administrators, dieticians,
emergency room staff, advocacy groups, dentists, pharmacists, and other
health care staff working in schools.
3.0 Key Issues for Strategic Attention
The Working Group discussed the underlying need for HCP outreach and
education, and the best approach from a strategic perspective for meeting
this need. These are outlined in Sections 3.1 through 3.4. Specific projects
which mirror this philosophy and direction are outlined in Sections 4.1
through 4.3.
3.1 Health Care Providers Could Use Information to Better Counsel
Their Patients on Drinking Water and Health
The NDWAC Health Care Provider Working Group believes that many HCPs
have only limited information to answer patient questions and concerns
about drinking water and health. Such questions may arise from any number
of sources, including media reports on drinking water system problems,
the issuance of boil-water notices by health officials, or patient interest
in specific findings shown in Consumer Confidence Reports being issued
by water utilities this year. While the Working Group noted that EPA provides
much information which is available to the general public, such information
may need to be revised and structured to be of most benefit to HCPs as
guidance on patient counseling.
3.1.1 Basic Principles
The Working Group suggests that EPA(3)
consider the following basic principals in developing such anticipatory
guidance.
- Health care providers would benefit from information on the basics
on drinking water and health. A knowledge of the linkages between
drinking water quality and both acute and chronic health effects caused
by infectious and non-infectious agents would be of benefit to many
HCPs. Such understanding would assist in effective diagnosis, treatment
and prevention in certain routinely occurring situations (e.g. patient
with gastrointestinal illness(4)).
- A wide range in information sources would be useful for HCPs.
Health care providers need information on how and where to find answers
to patient questions about drinking water and health. The information
sources could include those from EPA, CDC, HCP professional associations,
advocacy groups, and others. These sources can cover the full spectrum
of information; from applied solutions to ongoing research.
- Health care providers can serve many roles.
Information and outreach materials can assist HCPs who are interested
in serving in a proactive role with their patients/clients. With such
materials, HCPs could more routinely pose questions to their patients
that could tease out problems with local drinking water sources, and
consider such information in diagnosis, treatment and counseling.
3.1.2 Key Points for Anticipatory Guidance
The working group identified a number of more specific areas which could
be encompassed by outreach efforts directed at HCPs:
- Basic Water Safety: HCPs should note that drinking water
served by public systems in the United States (i.e. those that fall
within the SDWA definition) is generally considered safe(5)
for most people most of the time. Information on the compliance of local
water utilities with laws and regulations would help provide data to
HCPs; such information will be available in CCRs.
- Vulnerable Populations: Some segments of the population are
more at risk from possible illness from drinking water(6); in some cases even drinking water that meets
applicable federal and state standards. HCPs need to be aware of who
those populations are and take steps to advise them of these risks.
- Outbreak Recognition: Outbreaks of waterborne illnesses do
periodically occur. If drinking water is not routinely considered as
a possible etiology (causative factor) by HCPs during diagnosis, recognition
of an outbreak could be delayed or possibly missed altogether. The outbreak
could then afflict more people than would otherwise be the case. Clinicians,
laboratory staff, and pharmacists can each be the first to recognize
an increase in background rate of diarrheal disease which could be attributed
to an outbreak.
- Acute and Chronic Effects: Potential drinking water health
effects are not limited to acute disease effects, such as gastrointestinal
illness associated with microbiological pathogens. Outbreaks associated
with chemical contaminants have occurred, and longer term exposure to
chemical contaminants such as arsenic and radon are of concern. While
research to date is inconclusive, many patients are concerned about
longer term health effects from the byproducts of drinking water disinfection.
Information and guidance to HCPs would help them respond to such specific
issues.
- Laws and Regulations: While some HCPs might appreciate knowing
about basic federal and state drinking water laws, they would be more
concerned if there are deficiencies or violations of drinking water
systems which serve their clients. Any local training or outreach to
HCPs should mention these issues as well as suggest a possible response
to patient concerns.
- HCPs as Community Leaders: Many HCPs are community leaders
and can serve in roles beyond patient/client outreach and education.
These include providing peer education with HCP colleagues and organizations,
involvement in community education, participation in Source Water Assessment/Protection
programs, and active engagement with local water providers and public
health agencies in assessing needs for infrastructure investments in
supply and treatment technologies. HCPs can also play a more proactive
role in smaller communities where CCRs are not distributed by mail.
- Other Water Sources: Water from private wells and certain
smaller water supply systems may not be covered by federal or state
safety requirements. The burden of testing and treatment may fall on
the homeowner or property owner. HCPs should be aware of testing and
treatment options available to patients/clients in these situations.
- Alternatives to Tap Water: Since bottled water and home treatment
devices are considered by many consumers as alternatives to tap water,
HCPs need to understand the benefits and shortcomings of these alternatives.
HCPs need to be able to provide or to direct patients/clients to reliable
information on different point-of-use device performance, other treatment
alternatives (e.g., boiling water), and bottled water safety. Such information
should accommodate contaminant-specific concerns.
- Other Paths of Exposure to Contaminants: Contaminants may
be transmitted by a variety of means in addition to drinking water.
HCP communication should address disease prevention comprehensively
for these contaminants (i.e., in the case of Cryptosporidium
include drinking water, recreational water, food, contact with animals,
and sexual/hygiene practices).
- Needs and Opportunities for Disease Monitoring and Reporting by
HCPs: It would be beneficial if HCPs are sensitized to the importance
of appropriate testing and reporting of illnesses which might be linked
to drinking water system problems. Interested HCPs can play an important
role in helping public officials strengthen disease surveillance and
reporting efforts, and build better ties between health officials and
water utilities. Clinicians, laboratory staff, and pharmacists have
important data which can be shared and used to establish a baseline
rate of diarrheal disease in a community.
3.2 Basic Health Care Provider Training on Environmental Health
Should be Strengthened to Include Drinking Water
Section 3.1 of this report presents a number of principals and actions
which can help inform practicing HCPs on drinking water in their day-to-day
role as health care counsels. It has been made known to the Working Group
that a fundamental issue is the need to improve the knowledge base for
doctors, nurses, and other HCPs on environmental health issues, including
drinking water. Training in schools, and for practicing HCPs in continuing
education and re-certification programs, is key to changing key clinical
practice behavior relevant to drinking water. These approaches offer the
most lasting response to help HCPs reduce the adverse health impact of
drinking unsafe water. The Working Group supports strengthening this basic
understanding, and suggests that this issue should be addressed on a multi-media,
multi-problem basis.
To meet these overall goals, education and training programs to inform
health care providers about waterborne illness should be designed for
three specific stages in the clinical process: 1) practice environment,
2) diagnostic testing, and, 3) reporting. Educational tools and methods
should be specially designed for each of these levels of the clinical
process to achieve well-defined, stage-specific expected outcomes.
3.2.1 Improving the Health Care Practice Environment
The practice environment encompasses all patient interactions that might
be relevant to drinking water. These interactions include management of
acute illness due to exposure to contaminated drinking water, evaluation
of common symptoms (e.g., diarrhea) that may be caused by drinking water,
and response to concerns about drinking water. Training methods targeted
at the level of the patient interaction should increase the ability of
health care providers to appropriately recognize, report, treat, and prevent
as well as educate patients about issues associated with drinking water.
An effective strategy at this stage requires a two-part approach: 1) expand
the knowledge base of health care providers in drinking water, and 2)
address the barriers to integrating drinking water issues into usual clinical
practice. Strategies for education and training should consider how to
overcome potential barriers that may prevent health care providers from
addressing drinking water issues with their patients.
Historically, there has been very little health care provider training
on environmental health in medical schools, nursing schools, and other
learning institutions. Consequently, health care providers do not generally
include environmental exposures in the evaluation of most symptoms or
have difficulty responding to questions on environmental health issues.
Examples of tools and methods which could foster knowledge and practice
skills(7) include:
- Take an environmental health history
- Recognize the signs, symptoms, diseases and sources of exposure relating
to drinking water
- Identify risk factors for exposure to contaminated drinking water
and health effects
- Understand key environmental/occupational principles, epidemiology
and population-based health
- Identify the informational, clinical and other resources available
to help address patient and community drinking water health problems
and concerns
- Demonstrate awareness of the health concerns and problems in communities
where patients live and work
- Provide patient education/guidance including risk communication
- Understand the legal and ethical responsibilities of seeing patients
with concerns about drinking water
While the above points may seem obvious to many, a variety of barriers
may prevent integration of drinking water skills and knowledge into practice(8). These would need to be considered by EPA as it
approaches the issue of education from a broad perspective:
- Lack of time for HCPs to become involved in drinking water health
problems which may be complex and time consuming
- No reimbursement for time spent
- Overwhelming administrative tasks
- Potential for needing to interact with legal system which is discouraging
- Philosophical, political, social or cultural deterrents (e.g. disagree
with environmental activists)
- Do not agree with data on environmental illness
- Lack of confidence in patient's compliance (follow-up testing)
- Lack of a systematic method for incorporating the skills into practice
- Lack of peer or staff support
3.2.2 Improving Diagnostic Testing
The next stage in the clinical process that requires specific training
approaches covers the issue of diagnostic testing. Laboratory diagnosis
is fundamental to the recognition and investigation of individual illnesses
as well as outbreaks. Investigations of suspected outbreaks associated
with Cryptosporidium and Giardia in drinking water,
for example, have been shown to hinge on appropriate ordering and testing
for these specific ova and parasites. Health care providers may not be
aware of the need and benefit of certain laboratory tests to define etiologic
agents which might be related to drinking water problems. There also may
be constraints with managed care organizations approving such tests, or
with finding appropriate, affordable laboratories. Outreach, awareness
and education strategies should, therefor, include not only laboratory
organizations but health care management groups as well.
3.3.3 Improving Reporting of Disease
The third stage for specific educational intervention is reporting of
potential waterborne illness. Health care providers may be the first to
recognize an increase in diarrheal illness in a community. Reporting increased
illness to the local or state health department (even prior to laboratory
diagnosis) enables timely public health intervention.
A comprehensive strategy to inform health care providers about waterborne
disease and symptoms should include many strategies with their specific
expected outcomes targeted at defined stages of the clinical process.
The overall outcome for this educational effort is multi-dimensional (knowledge
increase and behavior change). Strategies therefore need to be multi-dimensional
extending beyond usual written modes of information dissemination as discussed
in Section 3.2.
3.3 Messages Should be Targeted on a Patient Group or Audience
Basis
In several meetings and conference calls, the Working Group grappled
with the question of what "messages" need to be communicated to HCPs.
The group considered whether there was one or more clear pieces of information
that needed to be transmitted to HCPs. In such a case, the emphasis for
EPA would then be less on the information, and more on the mechanisms
for communicating that information to the field. Examples in the health
care field were cited, including the role of the microorganism H.
pylori as a causative agent in stomach ulcers, and environmental
lead and children. The answers regarding drinking water issues were found
to be rather straightforward in some cases (such as the health effects
of nitrates on infants) and more complex or unresolved in other cases
(such as the possible link between disinfection byproducts and spontaneous
abortions). The set of messages will continue to change as more information
is uncovered about contaminants under regulatory consideration, as well
as those which are candidates for regulation.
The Working Group was pleased to see EPA making significant progress
in communicating health effects information to the public, an effort that
supports both regulatory development and the Consumer Confidence Reports.
Much of this information is available on an individual contaminant basis,
which serves many purposes. The Working Group felt, however, that a significant
unfulfilled need is for patient-specific, concise information packages.
HCPs receive enormous amounts of reports and other information, and are
challenged in sifting through this volume to find what is relevant for
their specific patients. Clarity and focus is needed to reach HCPs. If
they are treating people with asthma, for example, they will respond best
to information focused on asthmatics. EPA and CDC has developed guidance
on drinking water issues for immune-compromised patients, and EPA has
in draft form, a brochure on children and drinking water. This is an approach
which should continue and be expanded, such as for women of child-bearing
age and the frail elderly. Outreach is most effective when the messages
are aggregated to a given population group, such as those on non-public
water supply systems, or in areas with known waterborne illness or drinking
water risk (e.g. concentrations of arsenic or radon above standards).
The Working Group discussed a number of possible patient groups/audiences
for targeted outreach, including patients who:
- have a weakened immune system, HIV or AIDS
- are on chemotherapy
- are elderly and in poor health
- are infants
- take long-term, oral steroids for skin conditions, arthritis, etc.
- are on dialysis
- have had a transplant
- are members of under-served or disadvantaged populations with substandard
health care, limited education or limited health care access
- are chronic disease sufferers (e.g., end-stage congestive heart failure,
renal failure)
- have poor nutrition
The Working Group recognized that outreach to these audiences or patient
groups would cut across the contaminant-specific information products
historically produced by EPA and others. The Working Group for illustrative
purposes only, marked up the following matrix showing several groups
versus contaminants of concern. Note that this analysis was done only
for the purpose of exploring the idea, and should not be considered
as technically accurate. The intersects are marked by an "X" where
the effect is a health concern, and "?" where there is uncertainty to
be explained in the outreach materials.
|
Patient Group & Possible Risk |
Severely Immuno- compromise |
Women of Child-bearing age |
Infants |
Frail Elderly |
Non-PWSS & Private Wells |
General Population |
E. coli & Cryptosporidium |
X |
|
X |
X |
X |
|
Lead |
|
? |
X |
|
|
? |
Acute chemical (e.g. arsenic) |
|
X |
|
|
X |
X |
Disinfection byproducts |
|
? |
|
|
|
? |
Nitrates |
|
|
X |
|
X |
|
Radon |
|
|
|
|
X |
|
|
|
Regarding information presentation, the Working Group felt that
succinct fact sheets could be prepared along the following topics:
- Background to the issue
- How great is the risk (on a relative or absolute basis)?
- Where is the risk found (e.g. what types of systems, utilities,
or settings)?
- What is considered "reasonable avoidance behavior"?
- Why is there uncertainty (e.g. accuracy of certain tests)?
- Where to go for more information (e.g. government and non-government
Web sites or data bases; medical literature, etc.)?
On the last point, the sense of the Working Group is that EPA and
other U.S. Government information sources should make available,
or provide references or links to, all relevant research reports
on health and drinking water. This set can be broader than those
studies considered fully peer-reviewed and included in technical
support for regulatory action. Early or preliminary research results
should be noted as such. The Working Group felt that HCPs should
be given all the help they can if they decide to review the range
in literature relevant to patient needs, and not just restricted
to reports "cleared" by government agencies.
3.4 Links With HCP Networks Should be Strengthened
As pointed out earlier, the HCP community includes several million
practitioners of wide ranging interest, expertise, and position.
It would be an impossible task to try and reach them directly and
effectively. The development and distribution of outreach materials
will be greatly enhanced through partnerships with HCP organizations
and networks. While some national organizations work actively with
EPA on drinking water, pesticides, fish consumption, and other environmental
health issues, additional partnerships should be explored. Activities
with these groups could include:
- Engagement of the leadership of key national HCP professional
organizations on the need for stronger links between the communities.
- Participation at national or regional meetings to foster awareness
of the Consumer Confidence Reports, and basic drinking water and
health fundamentals. This could be greatly enhanced by forming
a cadre of experienced drinking water and health specialists who
can give presentations. Speakers bureaus could be supported by
making available standard information packages and flexible slide
presentations.(9)
- Providing input on fact sheet language regarding, for example,
health effects or reasonable avoidance behavior.
- Distribution of information materials via direct mailings, Web
site posting, inserts in newsletters, special sessions at national
meetings, etc..
EPA is developing a candidate list of Health Care Provider organizations.
The list includes the constituent groups the organizations represent,
contact information, names of journals, newsletters and reports,
major meetings, priorities for outreach, and other information.
The addresses have been added to the Office of Ground Water and
Drinking Water's mailing lists, which are supplied to staff when
they plan communication strategies. The group believes that some
of these linkages with networks will be sustained over the long
term, and some will be shorter-term to focus on specific products.
In either case, the Working Group is enthusiastic about the potential
benefits from closer linkages between the health care and drinking
water communities. EPA must use variety of approaches to partnership,
and learn what works and what does not.
4.0 Possible Health Care Provider Training and Outreach
Activities
4.1 Introduction
The Working Group recognizes that HCPs typically face more severe
health care concerns than drinking water contamination. Nevertheless,
many in the public are very concerned about drinking water issues
and will continue to seek advice from their HCPs. We also recognize
that EPA and its partners on implementation (states, public health
officials, water utilities, etc.) have a formidable job meeting
SDWA requirements within current and projected budgets. Nevertheless,
the Working Group believes that a long-term effort to educate and
inform HCPs on relevant drinking water issues should be incorporated
into SDWA implementation programs. A number of candidate projects
and activities were discussed by the Working Group over several
time frames(10), which follows from the discussion in Section
3 above.
4.2 Possible Activities to be Initiated in the Near Term
There are two main purposes for this set of example projects; which
could be started in the next two to three years and then be ongoing:
(1) responding to patient questions which arise from the Consumer
Confidence Reports, waterborne disease outbreaks, claims of water
filter and bottled water advertisers, etc., and (2) to set the stage
for longer-term HCP partnerships.
- Concise, patient group-specific information packages; emphasizing
risk characterization, assessment and avoidance. These materials
could be distributed by HCP professional associations as well
as EPA and CDC. EPA should try to present health effects information
(including avoidance behavior) in as clear and simple language
as is possible. The Working Group suggests that EPA draw on a
wide range of reference sources, and note where the results of
cause/effect research have been validated by peer-reviewed work,
and where there is still emerging science, scientific debate on
findings, and significant uncertainty.
- Adding such HCP information to EPA and CDC Web sites, with linkages
to numerous organizations and groups.
- A "needs assessment" of targeted HCP groups (particularly doctors
and nurses) to see how best to reach them with information on
drinking water. This could be done as part of a wider EPA effort
looking at other environmental health issues such as contaminated
fish and pesticide poisoning. Such an assessment could include
formative research (qualitative assessment, message testing, strategy
feedback, etc.) and ongoing assessments of message, audience,
and effects for each targeted health care provider group.
- Pilot projects for HCP outreach and education; to sharpen both
messages and outreach products, as well as ensure relevance. These
can be focused on specific patient groups, or areas where drinking
water contamination is of relatively greater health concern. It
could include developing local information resources to assist
HCPs with specific drinking water topics pertinent to their community
(e.g. taste and odor findings which do not constitute health risk).
The pilot projects could be carried out by non-government and
professional organizations as well as government groups.
- More routine coordination meetings between drinking water professionals
and national, regional, and state HCP organizations; to learn
about each others roles and responsibilities, and discuss possible
areas of mutual interest.
- Increased participation by drinking water specialists at national,
regional, and state HCP meetings and workshops.
- Training materials that provide HCPs with an appreciation of
the various routes of environmental exposure that can result in
the transmission of acute and chronic disease causing agents.
EPA and CDC could work in partnership with Government and non-Governmental
organizations and professional organizations on these.
- Formation of task forces and expert groups to plan for longer
term HCP education initiatives. These can include the senior-management
or policy level to achieve broader understanding and basic commitment.
- Establish a group of HCPs and representatives of HCP organizations
to provide
feedback and evaluation on effectiveness of these education
initiatives.
4.3 Possible Longer-Term Activities
It was clear to the Working Group that both university/graduate
curriculum as well as that for practicing HCPs, should be augmented
to include more information on environmental health, including drinking
water issues. This is not a "new" observation(11),
and has been the recommendation from a number of studies and task
forces. EPA is currently looking at expanding its intra-agency coordination
efforts to address longer-term education and practice change for
all environmental health concerns. The Working Group strongly supports
this, believing that only multi-media and cross-sector efforts would
be successful.
This multimedia/partnering approach is recommended since: (1) EPA
has a relatively small number of staff trained as health care providers
or in public health, (2) several EPA offices have promising initiatives
to reach health care providers regarding specific environmental
health hazards, (3) The Institute of Medicine has made recommendations
to Congress that environmental health should be integrated into
basic nursing and medical school education (see previous footnotes),
and this recommendation has not been substantially addressed, and
(4) several federal agencies and national professional organizations
have been involved in addressing this issue. Particular outcomes
from this effort could include:
- Encouraging medical, nursing, and other HCP schools to expand
their curriculum on the recognition, avoidance, and treatment
of environmental health problems. This could include the provision
of the actual training materials(12).
- Curriculum enhancement of continuing education programs for
practicing HCPs.
- Enhancing standard medical and nursing reference manuals.
- Preparing training materials through expert groups and professional
organizations.
- Establishing advisory bodies to oversee curriculum integration.
- Expanding environmental health internships.
5.0 Supporting Documents
This report is the final product from the deliberations of the
NDWAC Health Care Provider Outreach and Education Working Group.
Preparatory materials and interim working papers are available from
EPA if needed by NDWAC, and include:
- Background materials for the December 1998 and June 1999 full
Working Group meetings held in Washington, DC.
- Summaries of Conference Calls held in January, April, and September
1999.
- A working draft slide show on drinking water and health issues
prepared by several members of the Working Group.
6.0 Acknowledgments
The official Working Group liaisons to the full NDWAC (Jeff Griffiths
and David Spath) would like to express their gratitude to the members
of the Working Group for sharing their diverse expertise, and working
through particular issues or recommendations in a number of small
group efforts. This intersection of health care and drinking water
professionals was a fascinating and enlightening first step in what
we believe will be a fruitful longer-term partnership across the
sectors. We would also like to thank Ron Hoffer and Sherri Umansky,
the (respectively) Designated Federal Official and Deputy DFO for
this Working Group, who helped make the process go as professionally
as it did. Finally, facilitation support for full Working Group
meetings and several conference calls was provided by Paul DeMorgan
of the Keystone Center.
7.0 Attachments
1. List of Working Group Members and Liaisons
2. Additional background discussion on waterborne disease from
infectious agents
Attachment 1
Members and Representatives of the NDWAC
Dr. Jeffrey K. Griffiths
Department of Family Medicine & Community Health
Tufts University School of Medicine
136 Harrison Avenue
Boston, MA 02111
Dr. David Spath
Chief
Drinking Water and Environmental Management
California Dept of Health Services
(MS 216)
PO Box 942732
Sacramento, CA 94234-4320
Members
Ms. Simin Abrishami
Manager
Microbiology Department
NSF International
3475 Plymouth Road
Ann Arbor, MI 48105
Mr. Mark Anderson
Technology Transfer Director
Division of Water Supply Engineering
VA Dept of Health, Room 109-31
1500 East Main Street
Richmond, VA 23219
Mr. Phil Bastin
General Manager
Bean Blossom Patricksburg Water Co.
86 East Market Street
P.O. Box 186
Spencer, IN 47460
Ms. Kathy Blair
City Epidemiologist
City of Milwaukee Health Dept.
Room 112 Municipal Building
841 N. Broadway
Milwaukee, WI 53202
Dr. Jeff Davis
Chief Medical Officer & State
Epidemiologist for Communicable Diseases
Division of Public Health
Wisconsin Department of Health and Family Services
1414 East Washington Avenue, Room 241
Madison, WI 53703
Ms. Gabrielle Giddings
Environmental Health Coordinator
Clean Water Action
1128 Walnut Street
Philadelphia, PA 19107
Mr. Steve Hubbs
Louisville Water Company
550 South Third Street
Louisville, KY 40202
Janice Keller-Saul
Communication Manager
Washington State Department of Health
Drinking Water Division
7171 Cleanwater Lane, Building 3
PO Box 47822
Olympia, WA 98504-7822
Dr. George Lambert, M.D.
Associate Professor of Pediatrics
University of Medicine and Dentistry of NJ
Robert Wood Johnson Medical School
675 Hoes Lane
Piscataway, NJ 08854-5635
Mr. Steven Leonard
Water Quality Program Manager
San Francisco Public Utilities Commission
1212 Market St., Suite 310
San Francsico, CA 94103
Dr. Jane Lipscomb
Associate Professor
School of Nursing
University of Maryland Baltimore
515 West Lombard Street
Baltimore, MD 21201-1545
Dr. Jim Miller
Director
Parasitic Disease Surveillance Unit
New York City Departments of Health and Environmental Protection
Room 322, Box 22A
125 Worth Street
New York, NY 10013
Ms. Lisa Ragain
Campaign for Safe and Affordable Drinking Water
4404 South 6th Street
Arlington, VA 22204
Dr. Scott Ratzan, M.D.
Academy for Educational Development
1255 23rd Street, N.W.
Washington, DC 20037
|
Ms. Kitty Richards
Program Manager
New Mexico Border Environmental Health Office
New Mexico Department of Health
1170 N. Solano Drive, Suite L
Las Cruces, NM 88001
Ms. Deborah Rizzi
Manager, Communications
United Water Management & Services
200 Old Hook Road
Harrington Park, NJ 07640
Dr. Deborah Scott, M.D.
General Internist & Staff Physician
Alice Peck Day Memorial Hospital
125 Mascoma Street
Lebanon, NH 03766
Dr. Cathy Simpson, M.D.
Assistant Professor
Division of Occupational and Environmental Medicine
Department of Family Medicine (UHC 4J)
Wayne State University
4201 St. Antoine
Detroit, MI 48201
Dr. Raymond W. Thron, Ph.D., P.E.
Chair
National Council on Water, Pollution, and Health
National Association of Physicians for
the Environment
1043 Grand Avenue, #202
Saint Paul, MN 55105-3002
Federal Agency Liaisons
Mr. Patrick Bohan
Environmental Health Officer
Divison of Environmental Hazards and Health Effects
National Center for Environmental Health
U.S. Centers for Disease Control and Prevention
Mail Code F-28
4770 Buford Highway
Atlanta, GA 30305
Dr. Dennis Juranek
Associate Director
Divison of Parasitic Diseases
National Center for Infectious Diseases
U.S. Centers for Disease Control and Prevention
Mail Code F22
4770 Buford Highway
Atlanta, GA 30305
Ms. Donna L. Orti, M.S.
Chief
Health Education Branch
Division of Health Education and Promotion
Agency for Toxic Substances and Disease Registry
1600 Clifton Road, Mailstop E-42
Atlanta, GA 30333
EPA Liaisons
Mr. Ron Hoffer
Senior Advisor and Designated Federal Official
Standards and Risk Management Division
Office of Ground Water and Drinking Water
U.S. Environmental Protection Agency
401 M Street, SW
Mail Code 4607
Washington, DC 20460
202-260-7096
Fax 202-260-3762
hoffer.ron@epa.gov
Ms. Sherri Umansky
Communications and Outreach Specialist
Standards and Risk Development Division
Office of Ground Water and Drinking Water
U.S. Environmental Protection Agency
410 M Street, SW
Mail Code 4607
Washington, DC 20460
202-260-0432
Fax 202-401-6135
umansky.sherri@epa.gov
Keystone Center Staff
Mr. Paul De Morgan
Associate
The Keystone Center
1030 Fifteenth Street, NW
Suite 300
Washington, DC 20005
Ms. Shelby Hagenauer
Project Support Coordinator
The Keystone Center
1030 Fifteenth Street, NW
Suite 300
Washington, DC 20005
Ms. Judy O'Brien
Associate
The Keystone Center
1030 Fifteenth Street, NW
Suite 300
Washington, DC 20005
|
Attachment 2
Additional Background Discussion
on Waterborne Disease from Infectious Agents*
Diarrhea and abdominal cramping are the most likely symptoms to
arise following the ingestion of a waterborne infectious agent.
However, diarrhea and abdominal cramping are not specific to waterborne
infectious agents and may be due to exposures by other routes (e.g.,
foodborne, person-to-person) or to non-infectious causes. Diarrhea
and abdominal cramping may be mild and self-limited, and not lead
a person to seek medical care.
When diarrhea is mild, most people do not seek medical care. Self-medication
with an over-the-counter anti-diarrheal drug is the most likely
thing done by someone with diarrhea. If a person does opt to see
their HCP, the diagnosis of a specific cause of the diarrhea may
be of little use to the HCP in the care of that patient. Even when
a stool specimen is submitted for laboratory testing, Cryptosporidium
testing is often not done in a routine ova and parasite laboratory
examination. The number of laboratory-confirmed infections during
documented waterborne disease outbreaks is generally small. For
all of these reasons, HCPs, including laboratorians and pharmacists,
may be the first to recognize an increase in diarrhea in their community,
even in the absence of laboratory-confirmed cases of a specific
infection.
Waterborne outbreaks of infectious disease occur in various situations.
Water treatment (e.g., disinfection, filtration) can fail because
of a malfunction, or can be overwhelmed by a sudden large increase
in infectious agents entering the source water for the drinking
water system. Cryptosporidium is notable for its ability
to survive chlorination. Some water systems which use water derived
from underground sources are not disinfected at all, and can transmit
disease when contaminated water leaks into the well (e.g., during
a flood). Cross connections can occur, which allow waste water (including
human sewage and/or chemicals) to enter the drinking water system.
Small water systems often lack sophisticated monitoring and treatment
and may be at greater risk for transmitting a waterborne disease
agent.
* Note that this
discussion was prepared by Working Group member Jim Miller during
the final round of comments; it has not been reviewed by the Working
Group.
-------------
1. 1999, National Environmental Education
& Training Foundation, "The National Report Card on Safe Drinking
Water Knowledge, Attitudes, and Behaviors. Washington D.C., 55 pgs.
2. U.S. Bureau of Labor Statistics
SIC database as of July 27, 1999
3. While the Working Group directs
its recommendations to NDWAC, and then to EPA, it is assumed that
implementation goes beyond EPA's responsibility and budget. Collaboration
is assumed with CDC, other Federal organizations, and partners in
the HCP field both within and outside of government agencies.
4. More background information on
this issue is included as Attachment 2, as well as in "Cryptosporidium
and Water: A Public Health Handbook", prepared in 1997 by the Working
Group on Waterborne Cryptosporidiosis, and available from the Division
of Parasitic Diseases, CDC-NCID, Atlanta, Georgia.
5. One member suggests that it may
be more precise to communicate about levels of relative health "risk"
for specific water consumer populations than to communicate more
broadly about water "safety." The Working Group held only limited
discussion on this point, but readers of this revised draft might
wish to consider how this alternate "risk" terminology might substitute
where there are currently references to water "safety" in this document.
The member also notes as a practical matter that patients/clients
may be more interested in guidance about whether or not they should
drink their water, rather than whether or not their water is "safe."
6. As noted in Section 3.3 of this
report.
7. This list is meant to be illustrative
only, and is consistent with recommendations by the Institute of
Medicine in their 1993 report "Environmental Medicine and the Medical
School Curriculum" Washington, DC, National Academy Press.
8. Adapted from Pope, A.M., and Rall,
D.P. (Editors). 1995. Environmental Medicine: Integrating a Missing
Element into Medical Education, Washington DC, National Academy
Press.
9. A few members of the Working Group
prepared a generic slide show on drinking water to assist its members
who are participating in HCP meetings this year; the full NDWAC
consider whether (and in what form and venue) the slide show should
be made available for wider use.
10. As noted throughout this document,
while EPA is the principal audience for the Working Group's findings
and recommendations, it is not assumed that all (or perhaps even
a majority) of these can or should be carried out by EPA per
se. Instead, it is assumed that these would be considered by
EPA, CDC, and numerous professional organizations and advocacy groups
for implementation within available budgets and priorities.
11. See footnotes #7 and #8 for
example
12. Working Group members cited
several examples, including the CDC/EPA biannual summary of waterborne
disease outbreaks, ATSDR's updated case studies in environmental
medicine, presentation materials for medical/nursing school classes,
and continuing education programs.
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