Establishing Effective Public Health Partnerships Homer C. Emery, Ph.D. 1 Abstract Prior to President Nixon s creation of the Environmental Protection Agency (EPA) in 1970, public water systems were regulated from a public health perspective. The formation of EPA eventually led to the transfer of many former public health functions at both the Federal and State level to new departments of Environmental Quality. In many cases this shift from a public health focus in managing environmental health left many public water utilities without close ties to local health departments. Lessons being learned in today s reality of the terrorist threat to public water supplies and the impact that natural disasters such as Katrina can have on potable water systems underscore the need for water utilities to establish and maintain effective partnerships with local health departments. In San Antonio, Texas, local water utility operators have participated in simulated training exercises with local public health sanitarians to gain a better understanding of established local, state and federal emergency response networks. This paper reports how Don t Drink the Water, a simulated disease outbreak, was designed as a training exercise to introduce water utility operators to basic epidemiological techniques used by public health sanitarians in the investigation of a suspected waterborne illness outbreak. Participants composed of local sanitarians and water operators worked together in the investigation of a possible waterborne illness outbreak. Teams used mock patient histories to construct an epidemiological curve to estimate the time of exposure and to identify the most likely source of the illness. Using basic epidemiological techniques to calculate specific food and beverage attack rates, it was possible to identify the most likely cause of the illness. Partnerships established through Don t Drink the Water have led to improved planning for possible terrorist water contamination threats and a better understanding of established local, state and federal emergency response networks. Introduction Long before John Snow took the handle off London s Broad Street Water Well and stopped the 1854 cholera epidemic, the history of modern water treatment and public health have been uniquely linked. Filtration of public water supplies as a public health measure starting in the early 1800 s, the Sanitary Commission Reports of the mid- 1800 s, and the introduction of chlorine as a standard disinfectant in the early 1900s are just a few of the numerous examples how water treatment and public health have been historically linked. 1 San Antonio Water System, Member Bexar County Local Emergency Planning Committee 1
From the 1920s to the 1950 s state and local health authorities became more involved with local water and wastewater utilities. The great environmental awakening of the 1960 s and the publication of Rachel Carson s Silent Sprint led to a demand for better management of environmental problems and natural resources. Headlines news stories of massive fish kills and increased reports of toxins being found in the environment eventually led to President Nixon s creation of the Environmental Protection Agency (EPA) in 1970. With the creation of EPA as a cabinet-level agency, a number of new federal laws were quickly passed. The Safe Drinking Act of 1974 was one of the first major achievements in meeting EPA s mission to protect human health and to safeguard the natural environment. This was followed by regulatory initiatives nearly too numerous to count. By the beginning of the 1990s many of the former Public Health Service functions related to public water supplies at the federal level had been transferred to EPA. A similar transfer of public health functions was also taking place at the state level with the creation of new departments of Environmental Quality. In Texas and other states, an initial core of Sanitarians previously working in local and state public health agencies became environmental specialists assigned to these newly created departments of environmental quality bringing with them their public health perspective and experience. In time this shift from a public health focus created a gap between many public water utilities and their local health department. This gap will continue to grow, as this core of former public health Sanitarians in state environmental agencies are gradually replaced with younger environmentalists having less public health experience. During the 1993 Cryptosporidium outbreak in Milwaukee, Wisconsin, both the water industry and public health community were described as being asleep at the wheel. A similar trend in separation of public health from water treatment was also occurring in Canada, ending with the tragic consequences of the Walkerton E. Coli 0157:H7 outbreak of 2000. Following the terrorist attracts of September 11, 2001, Congress quickly passed the Public Health Security and Bioterrorism Preparedness and Response Act of 2002. This act directly amended EPA s Safe Drinking Water and recognized a need for establishing effective partnerships between public health and water utilities. In San Antonio, Texas, local water utilities recognized the need to establish improved partnerships with local public health officials. Working with their Local Emergency Planning Committee (LEPC), regional water utilities were able to participate in Don t Drink the Water, a waterborne illness outbreak simulation. Local public health Sanitarians, regulatory agency officials, emergency first responders, and water operators participated in this exercise sharing their expertise and experience. Following is a description and lessons learned from Don t Drink the Water. 2
Don t Drink the Water This training exercise was designed to introduce water operators to basic epidemiological techniques and other tools used by public health officials in the investigation of a suspected waterborne illness outbreak. At the same time local public health professional were able to learn and become familiar with new water utility tools developed for responding to the new terrorist threat. Participants included personnel from the San Antonio Metropolitan Health District, Region 13 Texas Commission on Environmental Quality, and water supply professionals from, Leon Valley, Live Oak, Universal City, Bexar Met, and the San Antonio Water System. Exercise Scenario 2 : On August 15, the 225th Air Guard Detachment at Brooks City Base (BCB) was notified to report for deployment processing on August 21. On August 20 th, a unit family picnic and fish fry is held at BCB Family Park with approximately 50 persons attending. On the same day, pressure testing of an irrigation system at City Base results in the backflow of an unknown contaminant into the water distribution system. Early the next morning three family members attending the unit picnic report to a civilian medical treatment facility with vomiting, fever and mild diarrhea. During deployment processing a few hours later at BCB, eight members of the unit being deployed are reporting similar symptoms. At the same time City Base and local water system operators are receiving complaints about water quality in the distribution system. Participants worked in multidiscipline teams consisting of water operators, sanitarians, epidemiologists and emergency first responders. Teams were provided situations with information on individuals experiencing symptoms of what appeared to be a waterborne illness outbreak. Discussion points were provided with each situation to emphasize terminal learning objectives. Using information provided, each team formed an initial hypothesis about the source of the outbreak and made decisions related to water quality advisories. Exercise Situations: Situation #1: Three members of the same family are treated at a local medical treatment facility for what appears to be water or food related illness having a common source. An intern working at the facility has just completed a training rotation at the San Antonio Metropolitan Health District (SAMHD). Knowing the importance of collecting laboratory samples and obtaining patient histories, the intern orders stool cultures and has an aid take detailed food and beverage histories. Patient histories are faxed to SAMHD. Learning Points: What constitutes an illness / disease "outbreak"? / How are terms such as endemic, epidemic and pandemic used to describe the occurrence of an illness? / Can information provided by the medical treatment facility be used to determine if a common source outbreak is likely? / Can symptoms be used to characterize the type of illness involved? Situation #2: A local water utility employee receives a phone call from a customer with concerns about illness and a water quality problem at Brooks City Base. The caller states, " I just had to take my three kids to the hospital because they're sick. This has got to be related to a water problem at Brooks I just heard about. A Senior Technical Sergeant in my unit just informed me 2 Not an actual event or military unit 3
that the system at Brooks is contaminated and my kids attended a picnic there yesterday afternoon. You need to tell everyone at Brooks to don't drink the water!" Learning Points: With this limited amount of information, what should employees at the water utility do? / Would you recommend that a "don't drink the water advisory" be issued based on this phone call? / Should other agencies and organizations be contacted? If so, what agencies and organizations are recommended? / Why should local water utilities report / share / coordinate information on customer complaints, especially illness complaints, with local health officials and regulatory agencies? Is this coordination required by regulation? Situation # 3: While processing for deployment at a medical treatment facility, eight members of a military unit at Brooks City Base begin to experience an acute illness. Symptoms include: nausea, vomiting, abdominal cramps, minimal diarrhea, fever and headache. During the next 20 to 30 minutes a total of 8 persons report similar symptoms of illness. Situation #4: The following phone call is received by water operators: Water from the drinking fountain at the Boy Scout Hut here at Brooks City Base is yellow. This really looks bad - do we need to have base officials put out a "Don't drink the water advisory" for all of Brooks City Base? After receiving this phone call, environmental technicians investigate and find that while a contractor was pressure testing an irrigation water line a cross-connection with the potable system allowed a unknown contaminant to enter the system. The incident was not detected until personnel at Boy Scout Hunt observed yellow water in the drinking fountains. Distribution System Flow Model Demonstration: Exercise participants were provided a demonstration of software and other tools (system maps, schematics) for tracking contamination in a water distribution system. The importance of being able to isolate portions of a water distribution system potentially contaminated was discussed. Situation #5: The Metro Health Team receives a fax from Brooks City Base Military Public Health. They are providing case histories for 8 members of a military unit with various symptoms of a waterborne or foodborne illness. They think it may be related to a unit picnic the day before. One individual in the unit also reports that three of his children were taken to a civilian medical treatment facility earlier in the morning. Learning Points: How can the shape of an onset graph be used in the investigation of an illness outbreak? / How can information in the case histories be used to identify a probable cause of the outbreak? / Would simple percentages of food and beverages consumed by sick individuals be helpful? / Initial analysis indicates that more than 90% of those sick have a history of drinking water at BCB. Is this significant? Situation #6: The Metro Health Team receives another fax from Brooks City Base providing information on people attending the picnic. Using information that is now available, an attack rate table is prepared to identify the probable source of the illness. The Metro Health Team also receives a lab report from the civilian medical treatment treating the three young children to report that Salmonella has been identified as the cause of their illness. Learning Points: Based on the attack rate table, what is the food / beverage most likely to have caused the outbreak? / Would you expect this type of food / beverage item to be normally contaminated with the organism reported by the lab? How could this food / beverage have been contaminated with this organism? / At this point can an all clear be given for the water distribution system? 4
Conclusion: Investigation by the health authority shows that water is not the source of the illness outbreak. Epidemiological procedures indicate that hot dogs consumed during a picnic are the most likely source of the outbreak. Field investigations find that a cross connection resulting in backflow from a margarita machine was responsible for the discolored water problem. Lessons Learned: During the exercise, facilitators collected information from tabletop participants to identify the following lessons learned for use in future planning: Don t Drink the Water Lessons Learned: Waterborne illness outbreaks are a rare event for the typical water utility. The majority of civilian medical treatment facilities do not have a good record of reporting gastrointestinal illnesses to local health authorities. When it comes to water quality and public health, coordination and reporting to local health and regulatory agencies must go beyond regulatory requirements. Public notifications and water advisories not addressed by a specific regulation are best made with input from local public health and regulatory officials. The most sophisticated computer flow models cannot replace accurate maps and knowledge of the distribution system. With 911 and national attention focused on biological weapons of mass destruction, more emphasis will be placed on the reporting of illness outbreaks in the local community to public health authorities. Improved reporting of gastrointestinal illnesses may result in an increase in the number of waterborne illness outbreaks being identified. Water utilities need to continually review and evaluate procedures for investigating water quality problems and dealing with a waterborne illness situation. Joint training and exercises with local health and regulatory officials can help to identify gaps in current plans. Tabletop Evaluation and Feedback: Participants were requested to complete both pre-and post-exercise questionnaires. Participants also completed an evaluation form at the end of the exercise. A review of the pre and post-exercise questionnaires and the exercise evaluation showed that: Prior to the exercise 31 % of the participants described their knowledge of how public health departments investigate waterborne illness outbreaks as being familiar. After the exercise, 65 % described their knowledge as being familiar. Prior to the exercise only 38% of the participants described their knowledge of tracking contaminants in a water distribution system as being familiar. After the exercise, 57 % described their knowledge as being familiar. 72 % of the participants described the exercise as being very useful. 68 % of the participants described the exercise as realistic. As a result of participating in this initial training exercise, the need to have coordinated plans in place for responding to possible terrorist water contamination threats and other water quality emergencies was recognized. Since taking part in Don t Drink the Water, regional water utilities, HazMat First Responders, and public health Sanitarians have participated in a variety of joint WMD contamination workshops and tabletop exercises. 5
Through a grant to San Antonio s Metropolitan Health District, local water utilities were also able to obtain field kits for improving rapid assessment of WMD water quality threats. Joint planning and training exercises have also resulted in a better understanding of how local water utilities and public health authorities fit into a Incident Command System (ICS) and the larger National Incident Management System (NIMS). By training water operators in ICS organizational concepts it was easier to deploy and support a water utility strike team to Mississippi in support of Hurricane Katrina emergency response efforts. Summary and Conclusions: For the vast majority of public water systems, waterborne illness outbreaks are a rare event. When it comes to major waterborne illness outbreaks, the U.S. water industry faces the same dilemma as the Maytag Repairman - We have little to do, but must always be ready to rapidly respond. Don t Drink the Water and similar training exercises can be a valuable training tool in helping water utilities to establish effective partnerships that will be critical when they do need to respond to a real water quality emergency. Similar joint training exercises involving both local public health department staff and state environmental agency staff may also help to close the gap between environmental and public health. In San Antonio, Texas, we are finding that the words of one Washington, D.C. emergency planner are very true Having an emergency response plan is a must, but having a friend on the response team is even better. Hotel Employees 6