Gelting, R. J.

Miller, M. D.

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Linking Public Health and Water Utilities to Improve Emergency Response22JOURNAL OF CONTEMPORARY WATER RESEARCH AND EDUCATIONUCOWRLinking Public Health and Water Utilities to Improve Emergency ResponseR. J. Gelting and  M.D. MillerCenters for Disease Control and Prevention (CDC), National Center for Environmental Health/Agency for ToxicSubstances and Disease Registry, Environmental Health Services BranchIntentional contamination of a drinking watersystem may be discovered in several ways. Ifthe potential contamination is unannounced orcovert, its first indications might be detected by thewater utility operating the system or by the publichealth system. In contrast, if a terrorist groupannounces a contamination event (or the threat ofone), water utilities and the health-care system bothmay learn about the event simultaneously throughsuch channels as mass media. Various otherscenarios are also possible, such as a threat beingtelephoned to a water utility. In all of these scenarios,water utilities and the public health system must worktogether to respond to real or threatenedcontamination of drinking water supplies.Water Utility and Public HealthSystem Responses to DrinkingWater ContaminationIf an event involves an obvious security breachrelated to drinking water, the water utility wouldlikely be the first to uncover the possibility ofcontamination. Security breaches associated withvandalism such as cutting locks or fences, are notuncommon. However, recent terrorism events andincreased awareness of terrorist intentions havehighlighted the need to handle these situationsdifferently than in the past.  As stated by the FloridaDepartment of Environmental Protection (DEP) ina letter to water plant owners and operators:“. . . we live in a new era. We must be much morevigilant and responsive about the security of ourwater supply systems to protect the public. Incidents,that in the past may have been viewed as acts ofmischief and vandalism, now need to be fullyinvestigated and managed seriously” (Florida DEP2003a).One element of managing these situations isinforming local and state health departments, andinvolving them in response efforts. This has notalways occurred in a timely manner. For example,in a recent drinking water system security breachin Florida that involved forced entry into watersystem facilities, 36 hours elapsed between whenthe utility discovered the problem and when theynotified the state health department (WaterTech2003). Events such as this prompted a change inpolicy in Florida to require water utilities to notify adesignated state emergency response hotline withintwo hours after any suspicious incident (Florida DEP2003b).Health departments need to know about potentialdrinking water contamination because they may needto be involved in responding to potentialcontamination incidents. Important elements of aresponse in the public health system includeinvestigation of any unusual patterns of illnesses,dissemination of guidance to the public to safeguardhealth, and preparation of treatment for peopleaffected by contamination (Fig. 1). Therefore, waterutilities and the public health system must not onlycommunicate but also actively work together toeffectively respond to potential contamination eventsinvolving security breaches of water systemfacilities.UNIVERSITIES COUNCIL ON WATER RESOURCESJOURNAL OF CONTEMPORARY WATER RESEARCH AND EDUCATIONISSUE 129, PAGES 22-26, OCTOBER 2004JOURNAL OF CONTEMPORARY WATER RESEARCH AND EDUCATION UCOWR23Gelting and  Miller Health Care Facilities (prepare for patients) Public Health System (investigate if illnesses occurring; disseminate guidance to public)  Water source   Treatment & Storage Distribution  Users Event Response Public Health Arena Event response(Investigate if contaminated) Event Discovery Security Breach  Water Utility Arena Figure 1. Response to a Water Contamination Event: Detection in Water UtilityWater Utility ArenaWater source Tr Storai tributionvent ResponseEvent DiscoveryPublic Health System(investigate if illnessesoccurring; disseminateg ida ce to public)Health Care Facilities(prepare for patients)Public Health Event Response(Investigate ifcontaminated)Security BreachAlthough methods exist for real time detectionof some contaminants in drinking water distributionsystems, such diagnostic tools are neither welldeveloped for detection of multiple unknowncontaminants nor deployed in a widespread manner.Therefore, if contamination does not involve anobvious security breach of drinking water systemfacilities, the first indication of contamination maybe patients seeking medical assistance at health carefacilities. The patients themselves may not knowwhat made them sick. However, if multiple patientshave similar symptoms, health-care facilities wouldnotify public health agencies, which would begininvestigating the cause and source of the illness. Inthe case of potential drinking water contamination,effective responses will require collaborationbetween water utilities and public health agencies.Although the public health system may discover theinitial contamination, much of the response will takeplace in the water utility arena, including actionssuch as identifying likely locations where an agentmay have been introduced into the water system,decontaminating the drinking water distributionsystem, and disposing of contaminated water (Fig. 2).Although it was naturally occurring,Cryptosporidium contamination of the Milwaukeedrinking water supply in 1993 provided an exampleof a contamination event discovered in the publichealth arena (Centers for Disease Control andPrevention [CDC] 1995). During a heavy rainfallevent, Cryptosporidium in the city’s surface watersource passed through the municipal treatmentsystem and into the drinking water distributionsystem. At that time, the city’s drinking watertreatment plant was not operating at optimal levelsfor treatment of Cryptosporidium, and high turbiditylevels caused by the rainfall as well as coldtemperatures contributed to the treatment system’slack of effectiveness against the organism. As peopleingested the parasite, many became ill withgastrointestinal symptoms, especially diarrhea.Public health officials discovered the contaminationbecause so many people sought treatment,especially over-the-counter anti-diarrhealmedications. However, long-term response to theproblem was the responsibility of the water utilitywho upgraded the drinking water treatment systemto make it effective against Cryptosporidium.If a terrorist group announces real or threatenedcontamination of drinking water in the media ordirectly to a water utility or public health agency, asolid partnership between water utilities and publicFigure 1. Response to a Water Contamination Event: Detection in Water UtilityLinking Public Health and Water Utilities to Improve Emergency Response24JOURNAL OF CONTEMPORARY WATER RESEARCH AND EDUCATIONUCOWRWater Utility ArenaCovert ContaminationWater source Treatment& StorageDistributionUsers(Decontamination,Disposal)Event Response Event DiscoveryEvent response(disseminate guidanceto public)Public Health System(investigate illnesses)Health Care Facilities(patient load up)Public Health Arenahealth agencies also would be required to dealeffectively with the event. To protect the public’shealth, decisions would need to be made quicklyabout, for example, whether chlorine is effectiveagainst the suspected agent, whether the affectedarea of the distribution system can be isolated, orwhether a boil-water notice should be issued. Publichealth authorities can often provide crediblemessages to the public, but will need criticalinformation from water utilities to craft the mostappropriate messages. Quickly disseminatinginformation to the public also will be an importantelement of a response, especially when terrorismmay be involved. Confusing and potentiallyconflicting messages need to be avoided, especiallyregarding actions the public should take to protectitself, highlighting the need for coordination.Communication problems were an issue for somecommunities during the widespread electricityblackouts in the Northeastern and MidwesternUnited States in 2003, when utilities and public healthagencies issued boil-water orders with conflictinginformation. The resulting confusion highlighted theneed for better coordination between water utilitiesand the public health system in responding toemergencies.Barriers to Collaboration BetweenWater Utilities and Public HealthAgenciesLocal public health agencies and water utilitieshave not always interacted and collaborated closely.Effective regulations and monitoring requirementshave prevented large-scale public health problemsin the United States related to drinking water exceptfor occasional failures in disinfection. In addition,many health departments are not involved in theregulation and monitoring of water supplies,especially for larger municipal systems. Stateenvironmental management or environmental qualityagencies (which generally are not part of state orlocal health departments) often monitor drinkingwater systems. Unless a disease outbreak involveswater, these groups have little need to interact.Differing technical language used by public healthagencies and water utilities also present barriers toeffective communication, especially if these groupshave not interacted in the past.Private contractors operating water utilities maybe reluctant to engage with local public healthentities because disclosure of information may affectthe status of their contracts with local government.Figure 2. Response to a Water Contamination Event: Detection in Public Health SystemJOURNAL OF CONTEMPORARY WATER RESEARCH AND EDUCATION UCOWR25Gelting and  MillerAdditionally, funding is not targeted to facilitate andmaintain relationships between public health agenciesand water utilities. Both water utilities and publichealth agencies have limited budgets and lackresources to get involved with activities outside oftheir legal mandates.Promoting Linkages Between WaterUtilities and Public Health AgenciesBecause of the potential for intentionalcontamination of drinking water supplies, waterutilities and public health agencies are beginning todevelop closer relationships. At the federal level, theEnvironmental Protection Agency (EPA), inconjunction with other federal partners such asCDC, is developing a response protocol toolbox forresponding to drinking water contamination threatsand incidents. The toolbox contains information toassist both water utilities and public health agenciesin emergency responses related to drinking water(EPA 2003).The Public Health Security and BioterrorismPreparedness and Response Act (Public Law 107-188) requires drinking water facilities to conductvulnerability assessments and prepare emergencyresponse plans.  Implementing or updating theseemergency response plans will increase opportunitiesfor public health agency involvement in planning andresponses at the local level. EPA’s newly releasedResponse Protocol Tool Box also encouragesinvolvement and inclusion of public health agenciesin water utility response plans (EPA 2003). Inaddition, EPA is organizing water security trainingsessions to educate water utilities, public healthagencies, law enforcement, and local governmentsabout water security issues and the need forincreased communication and partnerships. CDCand the American Water Works Association arepiloting smaller workshops specifically designed tobring local health department and utility staff togetherto address problems related to water security.Public health agencies in several major citiesthroughout the United States are implementingsyndromic surveillance programs designed to detectanomalies in disease patterns through the collectionand combination of multiple electronic data sourcesbefore confirmed diagnoses are made. Although notspecifically designed to detect waterborne events,the data gathered through these sources may helpincrease the speed at which events are detectedand data are analyzed (Mandl et al 2003).Conclusions and RecommendationsWater utilities and public health agencies needto develop stronger working relationships in orderto prepare for potential  drinking watercontamination events. In some cases, thesegroups previously have collaborated to addressspecific problems such as Cryptosporidium inwater, and those efforts can provide a templatefor collaboration related to terrorismpreparedness, such as in the formation of localtask forces (CDC 1997). Continued opportunitiesto collaborate also should be provided throughongoing training, planning, and joint exercises.For example, tabletop exercises can be usefulfor both water utilities and public health agenciesin identifying gaps in preparedness,communication, and response.Information sharing between utilities andpublic health agencies can enhance detection andresponse. For example, increased complaints towater utilities or public health agencies relatedto water could indicate a problem when coupledwith other public health surveillance data. Cross-referencing information,  such as water-distribution maps and locations of illness cases,also could improve responses. However, suchsharing would require that agreements be in placeto allow for information exchange withoutcompromising confidentiality issues for patientsor utilities.Establishment of formal agreements may helpensure regular exchange between utilities andpublic health agencies.  In some cases,requirements, such as the Florida policy requiringnotification of security breaches at drinkingwater facilities, may need to be mandated. Theactual mechanisms will vary among locations, butstate and local governments should explore waysto ensure regular communication between theseentities.Some efforts probably will require fundingdedicated to maintaining collaboration in planningand preparedness by water utilities and publichealth agencies. However, such collaboration willhelp ensure these entities are better equippedand trained to respond to both intentional andLinking Public Health and Water Utilities to Improve Emergency Response26JOURNAL OF CONTEMPORARY WATER RESEARCH AND EDUCATIONUCOWRnaturally occurring drinking water contaminationevents.AcknowledgementsThe authors acknowledge Dennis Juranek and John (Jay) Watsonof the National Center for Infectious Disease at CDC for theircomments on this paper.Author Bio and Contact InformationRICHARD GELTING, PH.D., P.E., currently works for the Centersfor Disease Control and Prevention (CDC) in Atlanta, and isinvolved in providing technical assistance to environmentalhealth programs at the state, tribal, and local levels. He hasworked in local public health programs with the Indian HealthService on the Navajo Nation in Arizona, New Mexico, andUtah and during his time as a Peace Corps Volunteer inHonduras, Central America. He holds Ph.D. and M.S. degreesin environmental engineering from Stanford University and isa registered Professional Engineer in the state of New Mexico.MARK D. MILLER, RS, MPH, is a Senior Environmental HealthOfficer with the Centers for Disease Control and Prevention.He holds a Bachelor of Science in Environmental Health fromEast Central University in Ada, Oklahoma and a Masters inPublic Health from the University of Texas and is a RegisteredSanitarian with the state of Texas. His 19 years ofenvironmental health experience includes, water, wastewater,food safety, injury prevention and hazardous waste.  He hasserved in positions with private industry, Indian HealthService, Agency for Toxic Substances and Disease Registryand is currently with the Centers for Disease Control andPrevention.ReferencesCenter for Disease Control (CDC). 1995. Assessing the publichealth threat associated with waterborne cryptosporidiosis:report of a workshop. Morbidity and Mortality Weekly Report(MMWR). 44(RR-6).Center for Disease Control (CDC). 1997. Cryptosporidium andWater: A Public Health Handbook. Atlanta, Georgia: UnitedStates Department of Health and Human Services, Centerfor Disease Control.Florida Department of Environmental Protection (FDEP).2003a. Letter to Plant Owners and Operators, January 23,2003. Tallahassee, Florida: Florida Department ofEnvironmental Protection.Florida Department of Environmental Protection (FDEP).2003b. Division of Water Resources Management,Permitting, Construction, Operation, Maintenance of PublicWater Systems, Rule Chapter NO: 62-555, Rule NO:62ER03-1, January 22, 2003. Tallahassee, Florida: FloridaDepartment of Environmental Protection.Mandl, K.D., J.M. Overhage, M.N. Wagner, W.B. Lober, P.Sebastiani, F. Mostashari, J.A. Palvin, P.H.Gesteland, T.Treadwell, E. Koski, L. Htwagner, D.L. Buckeridge , R.D.Aller, S. Grannis. 2003. Implementing syndromicsurveillance: a practical guide informed by the earlyexperience. JA Med Inform Assoc. Electronically publishedahead of print Nov. 21, 2003 as doi:10.1197/jamia.M1356.Available at http://www.jamia.org/cgi/reprint/M1356v1.pdfU.S. Environmental Protection Agency (USEPA). 2003.Response Protocol Toolbox: Planning for and Respondingto Drinking Water Contamination Threats and Incidents,Interim Final–December 2003. Washington, DC:Environmental Protection Agency.U.S. Public Law 107-188. 107th Cong., 1st sess., June 12,2002. The Public Health Security and BioterrorismPreparedness and  Response Act.Water Tech Online. 2003. Water security breach promptsstatewide security order. Available atwww.watertechonline.comNews.asp?mode=4&N_ID=37672

Linking Public Health and Water Utilities to Improve Emergency Response

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Linking Public Health and Water Utilities to Improve Emergency Response

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