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University at Albany Center for Public Health Preparedness

Water Contamination Events: Lessons Learned from Katrina

Original Satellite Broadcast: 02/09/06

Moderator: Hello and welcome to the University at Albany Center for Public Health Preparedness Grand Rounds Series. I'm Peter Slocum and I'll be your moderator today. Before we begin, I'd like to remind you to please take a moment after the broadcast to fill out your evaluation at the web address on the screen. We appreciate your feedback and it helps us in developing future programs. I'd also like to remind you that we'll be taking your questions live later in the hour. The toll-free number is 800-452-0662. You may also send questions by fax at any time during the program. That number is 518-426-0696. Today's program is on Water Contamination Events: Lessons Learned from Katrina. Our guest today is Dr. Patricia Meinhardt, who is currently executive medical director of the Center for Occupational Environmental Medicine affiliated with Arnot Ogden Medical Center in Elmira, New York. Welcome back, Dr. Meinhardt. It's good to see you again.

Dr. Meinhardt: Well, thank you. It's a pleasure to be with you again.

Moderator: We talked a couple of years ago about water threats from terrorist activity. We're going to focus more on natural disasters or potential disasters today, and preparing for events that are caused by hurricanes, floods, and so on.

Dr. Meinhardt: That's correct.

Moderator: How do you want to start focusing on the lessons learned from Katrina here?  Beginning with a brief description, maybe, of what you do at the Water Health Connection website?

Dr. Meinhardt: Well, I think I would like to address the topic today of disaster preparedness for water contamination events and I think we'll review a few of the lessons learned from Katrina. The massive water contamination resulting from the Gulf hurricane this year really highlighted the critical need for every community to incorporate disaster preparedness as part of their response plans. And that includes water disruption, as well as water contamination. And I think this includes, really, preparedness for natural disasters, as well as intentional acts of water terrorism. So, during the presentation we will review the unique challenges that are presented with respect to water contamination. That's when water systems might be damaged by natural disasters, man-made accidents, or acts of water terrorism. And then I think following that discussion, what I would like to do today is present a series of key disaster-preparedness strategies that are specific to water contamination, that I believe should be included in every disaster plan in order to protect the public's health. At the Water Health Connection we've done a lot of this work and we've had the opportunity to develop a variety of web-based medical guides and disaster tools that address waterborne disease, water contamination and water terrorism over the past four years. I'm author of two medical guides. The first one is “Recognizing Waterborne Disease and the Health Effects of Water Pollution”. I've also created another guide called “Physician Preparedness for Acts of Water Terrorism”. Both of these are accessible at our website - waterhealthconnection.org (one word). And I launched these medical websites to really assist healthcare providers, public health authorities, disaster managers, emergency-response personnel and law-enforcement personnel to manage natural disasters, man-made disasters, and intentional contamination of water supplies with biological, chemical, or radiologic terrorism. And it’s a fabulous resource. I'm very proud of it. My staff and I have been really gratified with the response. We've received about seven point eight million hits for information at the website over the past thirty-six months. We've also had the opportunity to train about ten thousand professionals across the United States, including public health folks, healthcare providers, emergency responders, and we've also done a lot of training sessions that include terrorism and disaster-preparedness exercises that address specifically the issue of water contamination.

Moderator: Well, it certainly is something that I'm sure our audience is concerned about and there's so much information, so let's jump into it here. Why is it that water contamination remains such a threat today?

Dr. Meinhardt: Well, I think we all clearly understand the vital need for water for basic human survival, and the need for this was clearly underscored in the aftermath of Hurricane Katrina. We also understand that contamination of water is a serious public health threat for many reasons. First of all, safe drinking water is vital for human survival, to prevent dehydration; second, water is essential for basic hygiene and modern sanitation methods; water is also key to every sector of our complex industrialized economy, as an essential component for production of many goods and services; and finally, uncontaminated water is really crucial to food production and livestock health, particularly in the agricultural areas of our country.

Moderator: That's something we don't think about so much, maybe here in the east, but it is indeed a critical factor. What are the primary sources of water contamination leading to disease and crises in the United States, and in other countries?

Dr. Meinhardt: Contamination of a community's water supply can occur from biological, chemical or radiologic compounds, and may result from many different factors - the first, natural disasters, such as hurricanes, earthquakes, and floods. And we have many examples of this type of water contamination ranging from the hurricanes this summer to the flooding that's occurring currently on the west coast of the United States. The second source is from man-made accidents, such as chemical or radiologic releases in source water. And Peter, I think the most extraordinary recent example of this type of water contamination is the accidental release of one hundred tons of benzene into the Chinese River that provides drinking water for some three hundred citizens in China and Russia. And third, of course, we can't forget that intentional contamination, or acts of water terrorism, is also a potential threat to water supplies. Water acts as a very effective delivery mechanism for many weapons-of-mass-destruction agents, and it's important for us to remember that intentional contamination of U.S. water supplies may be part of an organized effort by terrorists to damage our nation's critical infrastructure.

Moderator: What can happen to a community when its drinking water is disrupted? We saw, as you said, that example in China and Russia where three hundred million people were affected and this major city of Harbin was without water for well over a week.

Dr. Meinhardt: Correct. Even short-term disruption of water service can lead to serious medical, public health and economic consequences for a community.

Moderator: Can you share some of the examples of the known impacts that we're talking about, in addition to the Chinese example?

Dr. Meinhardt: I think one example that our audience is sure to remember, is the 1993 outbreak of waterborne cryptosporidiosis in Milwaukee, Wisconsin. During that outbreak, four hundred and three thousand Milwaukee residents developed diarrhea with a fifty-two percent attack rate - meaning fifty-two percent of the exposed population was affected with the illness. Also striking is over four thousand Milwaukee residents required hospitalization during that outbreak and cryptosporidiosis was listed as the underlying or contributory cause of death for fifty-four residents in the city who consumed the contaminated water. And this water event cost the city of Milwaukee in excess of fifty-four million dollars. That also included seven hundred and twenty-five thousand lost work days for the affected city residents who were ill. Now, remember these are 1993 dollars, so that cost of that outbreak would be far higher today.

 Moderator: Yes, indeed. And there's another good example in a much smaller community.

 Dr. Meinhardt: Absolutely. Another example from a small rural community is the waterborne disease outbreak with toxic E. coli that occurred in Walkerton, Ontario in the year 2000. In this small rural community with fifty-seven hundred residents, the municipal water supply was contaminated and that resulted in twenty-three hundred symptomatic residents, or a forty percent attack rate, with unfortunately, seven deaths, many of them in children, attributed to the contaminated water. It also resulted in eleven million dollars, which was required to reconstruct the community water system and provide them with temporary filtration. And believe it or not, the current costs of this waterborne disease outbreak for this small rural community have reached a hundred and fifty-five million dollars to date. So, I think these two examples really make it clearly obvious that the medical, public health, and economic consequences of a water contamination event can be devastating to both populated and rural communities. I want our audience to note the photo on this slide depicts a sign in Walkerton, Ontario during the outbreak, and it's quite compelling. The sign says E. coli, please go away.

Moderator: It had, indeed, dramatic impact on that small community.

Dr. Meinhardt: That it was.

Moderator: And as devastating as those numbers sound for a small community, they pale in comparison to the Katrina impact.

Dr. Meinhardt: Yeah, you're absolutely right, Peter. As a nation, we'll be addressing the devastating damage of that hurricane for many years to come. There, the water-delivery system, the wastewater system and the source-water network in the Gulf were impacted, which will require remediation of all of those various parts of the water network. I'm going to review just a few of the preliminary damage and the cost estimates to the water-delivery and the wastewater treatment systems in the Gulf that were caused by this massive natural disaster.  Preliminary estimates to the water system by Hurricane Katrina include one thousand two hundred and thirty-six public water systems were damaged or destroyed, just in Louisiana and Mississippi alone. Two hundred sewage-treatment plants were affected in Louisiana, Mississippi and Alabama. The power loss to the lift stations in New Orleans created sewage overflows into homes and businesses and the street, and fecal and chemical contamination of hundreds of miles of water-distribution pipes, and thousands of gallons of source water resulted from the hurricane damage.

Moderator: And yet you refer to preliminary estimates. Is it possible these are underestimations of the total cost that we'll see eventually?

Dr. Meinhardt: Peter, if we attempt to address the preliminary cost estimates of repairing just the public water supply systems damage by Katrina we have the following stunning number: In the hardest hit, high-impact counties of Louisiana and Mississippi, the estimated cost of repairing just the water supply infrastructure is two point two billion dollars. Now remember, this estimate does not include any of the substantial costs of repairing the wastewater system in these communities, or the cleanup costs of the source water that may have been contaminated.

Moderator: And these estimates come from the federal government or water professionals?

Dr. Meinhardt: These preliminary damage and cost estimates that we're going to discuss today are from a report commissioned by the American Water Works Association, which is the largest organization of water supply professionals in the United States.

Moderator: Okay. And that's why it focuses just on that piece of the problem here. But in all -- the whole range of healthcare and public health professionals are involved in responding to a disaster like this, as well as the whole sewage treatment plant's structure.

Dr. Meinhardt: Correct, Peter. Water systems damaged by natural or intentional disasters really create numerous unique challenges for many professionals, including medical, public health and emergency-response professionals, as well as water suppliers, public-works personnel, etc. And these challenges require a multidisciplinary team approach in order to effectively protect the public's health. So, the medical, public health and disaster-response challenges that are unique to water require careful pre-incident planning and very thoughtful post-event response strategies in order to be effective in protecting the public's health.

Moderator: Well, let's look at some of the basic, and sometimes overwhelming, response challenges that public health professionals face in these situations.

Dr. Meinhardt: It's extremely important to note, and I think part of the reason it requires such a coordinated effort is that water systems are very complex networks. When water systems are damaged - whether by natural, man-made or intentional means - many components of the water network need to be considered. First, we have the challenge of removing and disposing the contaminated water from both residential areas and industrial facilities. This was obviously a huge challenge in New Orleans after the hurricane, as is depicted in this photograph.

Moderator: Right.

Dr. Meinhardt: Second, we have the challenge of clean up and repair of not only the contaminated water plants, all the distribution pipes, water-storage facilities, the mechanical and electrical equipment, and the related computer-control systems that run these water utilities. These are each critical components of a community's water supply system. And remember, more than twelve hundred public water systems were damaged or destroyed in Louisiana and Mississippi alone after Katrina.

Moderator: Wow. So, that means that there are hundreds of professionals of various kinds of expertise that need to be involved in all this process.

Dr. Meinhardt: Yes, you're absolutely right, and that's really critical to understand in order for us to effectively prepare for the next water contamination event. We have another challenge, a third challenge to the water systems damaged by natural or intentional disasters, and that includes flushing, sanitizing, completing water-quality checks for every water-distribution line in all of the affected communities. That includes service to every residence and every industrial facility. And there's also the challenge of repairing hundreds of underground water-main breaks that may occur from flooding or earthquake damage.

Moderator: And there must be thousands and thousands of miles of pipe for people to check.

Dr. Meinhardt: That's correct, and it's just daunting when you think about the challenge.

Moderator: Yet we haven't even talked about the repair of the wastewater systems, which must be also a huge challenge.

Dr. Meinhardt: Another important challenge from water contamination from natural, man-made, or intentional disaster includes the clean up and repair of the wastewater system side of a water network. Clean up and repair of wastewater systems is vital in order to treat residential sewage, industrial waste, and agricultural runoff in the affected community. And this may involve all draining, cleaning, vacuuming and pumping each affected storm drain in the system. In fact, in New Orleans alone this involved draining, cleaning, and vacuuming fifty-five thousand storm drains to bring them back online for the city's use. What an immense challenge. But this is so critical to public health, and to providing appropriate sanitation for the city.

Moderator: The average person -- homeowner may think about getting a sump pump to pump out his or her basement, but it's a little more complex than that, especially when the city is a bowl shape, like it is, that if you don't fix that system, you're going nowhere.

Dr. Meinhardt: Correct.

Moderator: And of course, you have the problem of all of those residents trapped there with no clean drinking water while this repair is going on.

Dr. Meinhardt: One of the most critical challenges that we witnessed in New Orleans after the hurricane was the challenge of providing alternative water to New Orleans residents. Now, once the water-distribution systems are damaged or destroyed, distribution of alternative water supplies for all community water needs is vital until the water systems are back on line. Finding alternative water sources is a massive challenge, and then distributing them to all those impacted by the lack of potable water is a huge challenge. The photo on the slide that the audience is viewing is from New Orleans, and it illustrates this challenge. The sign actually reads, “Got Water?” And then it leaves a phone number to call to provide residents with potable water. So, as is apparent from the Gulf hurricanes, this is a major and costly, but exquisitely important, challenge to meet.

Moderator: And I'm sure we all remember seeing television footage of efforts to get tankers in with water for communities.  And the whole business of the bottled water - which was supposedly misdirected or whatever - it took a long time to reach there and the huge problem of providing that population with potable water.

 Dr. Meinhardt: The most important challenge to meet.

Moderator: Then, of course, we had the clean-up projects that flow from all this, and that's going to take years, decades?

Dr. Meinhardt: Potentially, yes. The clean-up efforts to address water contamination after a natural or intentional event - could potentially take years of remediation efforts in an affected community. First, there's the significant challenge of cleaning up the source water. That includes the rivers and lakes that frequently supply water to our public drinking water systems. Second, there is the challenge of testing and cleaning up contaminated groundwater that may also provide the community's drinking water. And third, there's the challenge of testing and cleaning up potentially tens of thousands of private wells in a community, particularly if this occurred in a rural area. And as you can see from the photo on the slide, this is a large petroleum slick throughout the source-water and wetlands area near New Orleans after Katrina, which is an illustration of this point.

Moderator: And every piece of this response and recovery is costly, I gather.

Dr. Meinhardt: Yes. The cost estimate of two point two five billion dollars from Katrina damage to the water supply systems that we discussed earlier does not include the water supply damage that resulted from Hurricane Rita. It doesn't include repair and replacement of all the damaged wastewater plants and systems. It doesn't include the clean up of the source water contamination. And it does not include the cost of supplying alternative water sources to the community residents during and after the event.

Moderator: Well, you've certainly impressed us with the scope of the disasters here. Is there anyone in the public health community who's exempt from or can be considered exempt from preparing for these disasters?

Dr. Meinhardt: Peter, I think everyone will agree the examples of water contamination events that we've discussed in Milwaukee, Ontario and New Orleans clearly illustrate the sobering consequences and extraordinary damage that can occur when water is contaminated in a community. Both metropolitan and rural communities in all areas of the United States need to prepare since water contamination can occur in their communities from diverse sources - natural disasters, man-made accidents or water terrorism. So preparing for water contamination is critical, in my opinion, for all state disaster response planning and execution. Now, one positive to note here is that preparedness strategies for water contamination have very broad applications to all types of hazards, no matter what the source. So, preparedness activities undertaken for natural disasters that affect water have a very positive impact on preparedness activities, let's say, for water terrorism and vice versa.

Moderator: I see. Well, knowing that natural disasters are inevitable and that terrorist threats are very real, what can we do to prepare for and ultimately protect our water sources and systems?

Dr. Meinhardt: Well, Peter, I think the key disaster and terrorism-preparedness strategy that every state and locality needs to embrace is this: careful disaster preparedness for water contamination events may make the difference between a controlled response in your community versus a public health crisis. Now, we obviously can't prevent these disasters from occurring, but we certainly can make a significant difference in protecting the public's health with thoughtful preparation and planning.

Moderator: And I know you would argue that even a disaster of the scope of Katrina could be prepared for more effectively and reduce the size of the disaster that people face.

Dr. Meinhardt: Correct. I think that's absolutely correct.

Moderator: Well, there are many unique challenges in preparedness to addressing water contamination events. What do you think are the critical strategies that all local and state governments need to include in their plans?

Dr. Meinhardt: Well, water contamination poses several unique preparedness challenges that require, I believe, very specific pre-incident planning and post-event response strategies. We're going to review fifteen key strategies today that address the unique preparedness challenges created when water is contaminated during a disaster. Now this is obviously not a complete listing of the disaster strategies that are necessary and we're really only going to be able to address them superficially today, but they're certainly good discussion points for state and local authorities to begin to consider. I also want to note that I've prioritized disaster strategies that address medical and public health challenges created when water is contaminated in a disaster scenario. Now, I know some state and local plans may have already incorporated these strategies, but I also know that many others have not. So, I want our audience to know that my staff and I are available to work with them to develop and implement these strategies in their home agencies and institutions, and we'll talk a little bit more of that opportunity at the end of our program.

Moderator: Okay. Well, let's begin with the first strategy in this framework for addressing these overall problems.

Dr. Meinhardt: The first key disaster strategy is extremely important to incorporate in all disaster planning. We all need to understand that preparedness for water contamination events is critical in order to first reduce the public health impact and the medical consequences of water contamination. Second, it's extremely important to reduce the secondary disruption to potable water delivery and wastewater treatment that's necessary for appropriate sanitation. And third - an extremely important point - we need to address this in order to reduce the psychological impact of the public's lack of confidence in water safety and quality during and after a disaster event.

 Moderator: What are the key measures to take to prepare for an incident?

Dr. Meinhardt: Another key strategy, and we've discussed this a bit with the consequences in Katrina, is to ensure that alternative sources of water are part of every disaster-preparedness plan.  This is necessary in order to guarantee that affected communities have adequate potable water for days to weeks after a contamination event. In some situations, if a water delivery system is seriously damaged or contaminated, alternative water sources may be needed in the community for an extended period of time, possibly months. And that's not just drinking water. We have many water needs – cooking, bathing, and water is essential for business and commerce in an affected community. The photo on this slide that our audience is viewing depicts the community water distribution system in Walkerton, Ontario, where tens of thousands of gallons of bottled water were distributed during their water contamination event. Now remember, this is the amount of water that was needed for a community of fifty-seven hundred residents. Alternative water sources were clearly an issue during Hurricane Katrina. So, preparing for this scenario in advance is critical to protecting the public's health and preventing illness and death.

Moderator: So people need to know where they're going to get alternative clean water for their community and how they're going to get it there.

Dr. Meinhardt: Distribution is a huge issue, as well.

Moderator: Right. Well, as we saw in our last program in this series - which was about preparing for response needs of people with special needs, and those propose their own kinds of challenges - our guest, Ana-Marie Jones spoke about the need to change our mindset about special needs population. That we shouldn't prioritize, but instead consider and prepare for everyone's needs. And you see this in the water field as well, I gather.

Dr. Meinhardt: I could not agree more. The most important point I'm making today is the following: all disaster response plans must prioritize the special needs of susceptible populations who are at increased risk for illness and death from dehydration, waterborne disease and the health effects of water contamination. It's extremely important to remember that water-related disease may present as benign symptoms and a self-limited illness in a healthy population, while the same exact water contamination exposure in a vulnerable population may result in significant illness and death. Remember that the majority of deaths in both Milwaukee and in the Walkerton waterborne disease outbreaks occurred in vulnerable populations. So, all disaster planning for water contamination events must consider the needs of sensitive populations. And let me just run through them for everyone again: Pregnant women and developing fetuses, neonates, infants and children, geriatric individuals - including nursing-home residents, immunocompromised and immunosuppressed individuals, and any patient with a preexisting chronic disease that would impair their renal, hepatic, or immunologic system. The photo on the slide that we just had up is of a five-year-old resident in Walkerton, Ontario who is receiving her bottled-water ration for the day during the waterborne disease outbreak.

Moderator: Her own part of the distribution system.

Dr. Meinhardt: Her own part of the distribution system.

Moderator: But of course, you have cancer patients undergoing chemotherapy treatments and HIV patients who are good examples of members of communities all over the country who are most likely to be affected in that kind of a circumstance.

Dr. Meinhardt: That's why it's so critical that we address the needs, when it comes to water-related disease, of vulnerable population.  It's key to protecting the public's health.

Moderator: Now, disaster strategy number four, I understand, relates to the roles of local medical and public health officials.

Dr. Meinhardt: It's critical that each disaster plan embrace the importance of local, medical and public health practitioners. They're going to be the front-line responders, often times in detecting and certainly in managing the water-related disease that results from natural, man-made or intentional water contamination. Our local healthcare providers and public health departments continue to be on the front lines when water contamination occurs in their community. The most likely initial indication that a water contamination event has occurred may indeed be a change in disease patterns or illness trends in a community. I think it's important to note that during the Milwaukee cryptosporidiosis outbreak, an astute family medicine physician noticed an unusually high rate of diarrhea in his nursing-home patients and that was the initial warning sign of the waterborne-disease outbreak that occurred in the city. So, it is so extremely important that local medical and public health community professionals be included in all disaster planning for water contamination events.

Moderator: So, they can be part of an early warning network, as well as a treatment-responder network.

Dr. Meinhardt: That's correct. That's a good point.

Moderator: Beyond actually drinking water that's contaminated, what other ways are people potentially exposed to contamination?

Dr. Meinhardt: Well, I think in order for disaster planning to be effective and protect the public's health; we really need to recognize that there are multiple pathways for human exposure to contaminated water during a disaster event. That includes not only ingestion, but aspiration of contaminated water.  That includes dermal absorption of contaminated water during recovery efforts or bathing with contaminated water.  That includes consumption of food directly contaminated with water during food preparation and it includes consumption of food indirectly contaminated by water via contaminated food chain or agricultural practices.

Moderator: Do you think the public is aware of this kind of threat from contaminated water? And -- expanding our definition of the public a little bit – were the emergency response people in New Orleans cautious enough about this potential?

Dr. Meinhardt: Well, as part of our disaster planning, we clearly need to protect the public and educate them about water contamination risks, so they can minimize their exposure. However, we also need to be especially vigilant about protecting emergency-response workers, medical workers, National Guard troops, the water-utility and the public-works personnel involved in clean up efforts as well. These emergency-response groups may be at increased risks of water-related diseases, and they may also need special protection after a water contamination event.

Moderator: How easy is it to diagnose or detect all of the potential waterborne diseases that are likely to flow from these disasters?

Dr. Meinhardt: It's important to recognize that many of the water-related diseases and syndromes that are associated with water-disaster events may be very unusual presentations of diseases that are not commonly seen in the community. Healthcare providers may be faced with diagnostic challenges for months in the Gulf region, with unusual presentations of water-related diseases. Now, many of the local healthcare providers are going to be unfamiliar with these diseases and disorders because they're not part of their typical clinical practice. After Hurricane Katrina, the CDC posted very valuable information for healthcare providers and local public health agencies, detailing the signs and symptoms of the hurricane-related waterborne diseases at their cdc.gov website, in order to assist the local healthcare providers and the local public health community with these unusual presentations.

Moderator: So, its a little variation on the usual prescription of when you hear hoof beats, you think of something besides horses maybe, in this case.

Dr. Meinhardt: In this case it's probably zebras.

Moderator: Right. Okay. We just discussed some of the waterborne disease from biological pathogens, and it's also important to understand there are medical challenges evaluating chemical exposure, as well.

Dr. Meinhardt: Well, let me just run through some of the unusual biological diseases that were seen after Hurricane Katrina. The list on the slide is very unusual. We have a variety of diseases that we frequently don't see except during water-related disasters, and it's important for healthcare providers to know that. It's also important to remember that addressing the medical consequences of chemical contamination of water can be a huge challenge, and that needs to be included in disaster-response strategies and planning. There are specific medical challenges to evaluating water-related diseases that result from chemical agents in flood or contaminated water. This is a challenge because there is a massive spectrum of medical consequences and sequela from chemical agents, ranging from mild symptoms to severe tissue damage - depending upon the toxicological profile of the waterborne chemical agent.

Moderator: Can you list some of the contaminants found in the New Orleans floodwaters after Katrina?

Dr. Meinhardt: Preliminary estimates indicate contaminated water in New Orleans contained six point seven million gallons of petroleum from damaged refineries, and chemical contamination for more than three hundred and ninety oil spills.

Moderator: Could you put that in perspective? How big was the spill that everyone knows about in Alaska from the Exxon Valdez?

Dr. Meinhardt: The National Oceanic and Atmospheric Administration, or NOAA, estimates that ten million gallons of oil were spilled in the Prince William Sound by the Exxon Valdez, which is again an example of how a man-made accident can create a huge water contamination event.

Moderator: We all know how complex and lengthy that clean up is - in some respects still going on. How long is it going to take to clean up this pollution in the Gulf and the water supply there?

Dr. Meinhardt: It's important to remember the Exxon Valdez oil spill occurred in 1989. The remediation efforts took years and the long-term environmental monitoring lasted for ten years after the initial oil spill. The clean-up efforts from the waterborne chemical contamination in the Gulf will require the same long-term and dedicated effort by all of us for the cleanup of environmental damage that's occurred there.

Moderator: And obviously the clean-up efforts are still underway and are going to be for quite a while.

Dr. Meinhardt: The clean-up efforts continue, and this is a huge challenge to address. It's important to remember that water is an excellent solvent and can act as an effective carrier of multiple chemical agents during a hurricane, flood or water-terrorism event. Estimates indicate the contaminated water in New Orleans also contained one to two million gallons of gasoline from damaged gas stations and the chemicals that were released from three hundred thousand flooded automobiles.

Moderator: Oh, my word. Oil spots on the driveway have nothing on that; right?

Dr. Meinhardt: No.

Moderator: In addition to the petroleum products, what were some of the other major sources of chemical contamination in the water in New Orleans?

Dr. Meinhardt: The contaminated flood waters may also have contained chemical compounds.  You have to remember that in this affected region there were thirty-one hazardous-waste sites and four hundred and forty-six industrial facilities in the flood zone that used hazardous compounds such as lead, mercury, hexavalent chromium, arsenic, benzene and pesticides. The photo on this slide illustrates the type of waterborne exposure that some of the residents in the hurricane region experienced from this contaminated water. So, obtaining an accurate exposure history and evaluating this resident for the short- and long-term health effects of this type of waterborne exposure to chemicals will be a serious medical challenge.

Moderator: Here's a person swimming through an oil slick or some kind of chemical contamination. Do we have any information yet regarding the long-term health effects that people are going to experience as a result of these contaminants?

Dr. Meinhardt: Well, another disaster strategy that we need to embrace and incorporate into our disaster-response plans is the fact that there may be co-infections with multiple waterborne pathogens or biological compounds, coupled with multiple chemical-agent exposure in the contaminated water. And that may result in both acute and delayed symptoms in both the affected residents and the emergency-response workers. This really complicates accurate and timely diagnosis of the health effects from the exposure in the Gulf. Therefore, additional resources may need to be available to address long-term health effects experienced by residents and emergency and medical workers in the Gulf. For example, long-term medical surveillance by local and state health departments and the CDC will be important in the Gulf region. It's important to note that there is a wealth of information at the CDC website that is specific to Hurricane Katrina and the flood-related health effects.

Moderator: And I think that it's good to stress that particular preparedness point, because many people watching today are probably part of the emergency-response teams or would be leading those involved in this kind of a response.

Dr. Meinhardt: It's not a disaster strategy that you want to forget. It's extremely important to be thinking about the long-term consequences, as well.

Moderator: Right. Well, often preparedness attention and subsequent media focus is on urban areas.  And we certainly have heard tons of information about New Orleans ever since the disaster, but there's a focus on rural areas in your disaster strategy that's equally important.

Dr. Meinhardt: Another important disaster strategy for all states and localities to understand with respect to water contamination is that disaster planning with the medical and public health community is critical to both populated and rural areas. Water systems in small, rural communities are equally at risk as metropolitan and municipal water systems for natural disasters, man-made accidents, and water-terrorism-contamination events. So, preparedness strategies for water contamination is vital, no matter how small or large the community. And I think the examples of the serious medical, public health and economic consequences suffered by the rural community of Walkerton, Ontario makes my point.

Moderator: As a matter of percentage, there may even be a bigger impact than in a big city.

Dr. Meinhardt: I think that that's probably the case, yes.

Moderator: In terms of the environmental impact, I assume there are both short- and long-term issues that need to be considered.

Dr. Meinhardt: It's important to implement preparedness strategies and countermeasures that address both short- and long-term consequences of water contamination events. A water contamination event has the potential to produce delayed, prolonged and environmentally mediated health effects for weeks to even years in a community. In emergency situations such as Hurricane Katrina, the EPA serves as the lead agency with the affected states for monitoring short- and long-term environmental impact on water in the Gulf region. And the EPA emergency-response personnel are going to continue working with the state and local agencies to assess health and environmental conditions for many years to come, as is the case with the CDC.  It's important for our audience to know the EPA also has a wealth of information on their website that's specific to water contamination in the Gulf, and they are posting their ongoing environmental-monitoring results right on their website.

Moderator: I see, in a real effort to open up communication.

Dr. Meinhardt: Correct.

Moderator: As we can see, there's no assurance that those projects are not without controversy - as we've seen in the aftermath of the September 11th health-monitoring issues in New York City. What about the importance of good communication between public agencies and the public and other agencies?

Dr. Meinhardt: Another important strategy to incorporate in all disaster plans is to acknowledge the fact that medical and public health practitioners are going to be faced with providing credible and timely risk communication to not only their patients, but the public in many situations, after a disaster resulting in significant water contamination. Many surveys indicate that healthcare providers are still among the most trusted source of information for the general public regarding drinking-water quality and safety. And you can be sure that community residents are going to turn to their local healthcare providers and public health leaders for advice regarding safety of their water during and after a water contamination event. So, I think communities will benefit immensely from involvement of local physicians as part of risk-communication efforts that public health departments are organizing. And I think that the photo on the slide is important for our audience to note. This depicts the Ontario prime minister addressing the residents and media in Walkerton, Ontario after the water contamination event that occurred there. There is a hand-made side in the crowd that states "We demand answers." So, this is obviously a public-communications nightmare and an example of where local public health and medical leaders would be invaluable partners in addressing the public's concerns.

Moderator: I remember a previous guest on our program here saying that while the training for communication is far less than half the time spent by preparedness people, well over half the time in an actual disaster is spent on communicating with the public effectively.

Dr. Meinhardt: I would agree with that percentage. It's extremely important.

Moderator: How can hospitals and medical professionals best prepare for an incident, particularly for vulnerable populations who are most at risk?

Dr. Meinhardt: Another extremely important disaster strategy is conscientious preparation for significant surge capacity at medical facilities, based upon the potential for large numbers of casualties exposed to contaminated water at the same time. Remember from our example of the waterborne cryptosporidiosis outbreak in Milwaukee, four thousand residents needed to be hospitalized after consuming contaminated drinking water. Now that's a serious strain for any medical facility or any community's medical facilities to manage. And remember that water-related disease in vulnerable population can be deadly, and these patients may need emergent and very sophisticated medical intervention. So, it's extremely important to prepare for the potential scenario of a large number of patients from a water contamination event, and also prepare for seriously ill patients after a water contamination event. The photo on this slide depicts a five-year-old girl from the waterborne toxic E. coli outbreak in Walkerton, Ontario. She's being evacuated by helicopter to specialty medical care with hemolytic uremic syndrome, which is a medical emergency that resulted from exposure to the contaminated drinking water in the community that she consumed.

Moderator: So, the bottom line, there's no one who can be exempt from preparation here. Can you talk a little about the need for collaboration with different responders and potential actors?

Dr. Meinhardt: What I hope is apparent from the examples that we've discussed today is that there is a real need for collaborative partnership with a multidisciplinary team approach when preparing for and responding to water contamination events - both locally and regionally. Disaster strategies addressing water contamination need to include teams of not only healthcare providers, public health officials, but water-utility practitioners, public-works personnel, emergency-management and disaster-response personnel. We also have the important groups, including National Guard troops, law-enforcement personnel, state and local government, community leaders and public risk communicators and media representatives. I also think it's important to include public and private-sector industry and businesses in these teams, since many of them will need water to continue their services. And in many situations they can be an extremely helpful resource in providing bottled water and assistance in water contamination events.

Moderator: And of course heavily impacted in terms of having their workers be able to come to work. If it's in an agriculture-related business in a contamination event, as we've talked about before, it could be shut down.

 Dr. Meinhardt: They're often not included in disaster-response teams, and I believe they're a critical element.

Moderator: Well, how well would you assess the country's preparedness? I mean, do these interagency networks or teams exist around the country?

Dr. Meinhardt: Peter, as I've been providing training across the country, I would have to say that the model of this interagency cooperation that we've talked about is very inconsistent throughout the United States. The graphic on the slide that I'm presenting this morning is really the model for a disaster response to water contamination events, and I hope that our audience will embrace and include this in their disaster strategies. This model requires a multidisciplinary effort from diverse disciplines that are traditionally not used to working together, so it's a challenge just to get everyone at the same table. Each member of the team must understand the critical role and importance of communicating effectively, coordinating their efforts and collaborating to protect the public's health in the event of a water contamination event. The three Cs of disaster and terrorism preparedness absolutely apply to water contamination disasters, and they are: Communication, Coordination and Collaboration.

Moderator: Now, what recommendations do you have for our audience today to become better prepared for the next disaster or event that disrupts the water system in their area?

Dr. Meinhardt: Well, I hope that our discussion today will encourage our audience to include water disruption and water contamination in their local and state exercise scenarios, their tabletop exercises and in their emergency-response plans. I would also encourage them to customize their disaster scenarios and exercise plans to reflect field conditions at the local, state or regional level, that address water hazards specific to the area needs and challenges.

Moderator: And what's the final strategy that you would like to leave our audience with today?

Dr. Meinhardt: Well, my final recommendation is to arm your medical, public health, and emergency-response and disaster-management communities with information and ready-made disaster tools that specifically address water contamination. These professionals need ready access and practical information that addresses biological, chemical and radiologic contamination that may occur from a natural disaster, a man-made event or intentional contamination of water in order to effectively protect the public's health.

Moderator: Now, we touched on this a little bit at the beginning, but what resources are available to assist state and local municipalities in preparing for these disasters?

Dr. Meinhardt: Well, I'd like to encourage our audience to visit our Water Health Connection website. On our website we've summarized and cataloged more than a hundred and seventy-five other websites that provide valuable information on waterborne disease and the health effects of water contamination, from not only natural and accidental contamination of water, but intentional contamination. Access to our website is free, it's available twenty-four/seven, and there's access to more than nine hundred web pages of comprehensive information dedicated to water. All of our website information has been peer reviewed by leading experts from public health, medical academia and military medicine. And the website has a section dedicated to not only natural and accidental contamination of water, but another section solely dedicated to preparedness for acts of water terrorism.

Moderator: So, it's a bit of a peer-reviewed clearinghouse or encyclopedia.

Dr. Meinhardt: I like that description.

Moderator: All right. Now, do you consider the reference guide and other information available there to be helpful for professionals who are not in a medical or direct public health field, as well?

Dr. Meinhardt: Well, Peter, although the targeted audience for these guides was originally physicians, we clearly have a very broad user base and I'm thrilled that the resource has been useful to those outside the medical field, as well. Users include environmental-health specialists, public health authorities, emergency-responders, and disaster-management, law-enforcement, water-quality and security specialists - to name a few. The website has also been used by several branches of the U.S. military, the U.S. State Department and even the FBI.  And I'm pleased to note that medical and public health specialists from eighty-nine countries now currently use this website as a resource for waterborne disease and preparation for water terrorism.

Moderator: Well, excellent. And perhaps the traffic will increase after today. Can you tell us how people can contact you about these training opportunities that come out of your center?

Dr. Meinhardt: I'd like to invite our audience to contact us if we can assist them in any way with their disaster strategies and terrorism preparedness efforts for water contamination. They can contact us via our website: www.waterhealthconnection.org. There are “Contact Us” options throughout the site, and my staff checks and responds within twenty-four hours. So there's always an easy and quick way to contact us. And we'd be thrilled to help any member of our audience who's addressing these very serious challenges.

Moderator: Do exercises and training programs already exist that people can have access to - rather than spending time to create them themselves?  Do you actually have exercises set up?

Dr. Meinhardt: Peter, I think our audience would be surprised to note that there are many exercises already available for use. For example, the EPA has developed a vigorous response program and has a series of modules that address preparedness for water protection and water security. And one entire guidance module they've created was specifically prepared for the public health, law-enforcement and emergency-response, and risk-communication communities - who might be faced with an intentional water contamination event. These exercises have broad application to other types of water disasters as well. They're very comprehensive, they're free, and they're available electronically. So, there are resources available for our audience.

Moderator: Excellent. Well, let's see. I think we have time for a couple of calls, if I'm right. We're ready to take those calls and the toll free number is 800-452-0662. You may also send in written questions by fax to 518-426-0696. And while we're waiting for the phone to ring, I want to ask - do you have specific recommendations for members of the audience about how to build and sustain the team approach that we've been talking about?

Dr. Meinhardt: I think that all of us feel from the events that occurred this summer in the Gulf region, how critically important it is for us to have the team approach, to have developed protocols for who makes decisions - when the decisions are made and understanding that the decisions - certainly around a water contamination event - must be timely, and must be appropriately integrated into a system so that residents and all emergency workers are protected. So, the team approach is extremely important, and the practice of the team approach is extremely important. Not just paper exercises, but the idea of putting all members of your disaster-response team together, and actually walking through the potential scenarios in your community. I have found that when I've done this for communities at both the state and local level, it's extraordinary what each element of the disaster-response team in a community does and doesn't know about what the others are able to provide. So, what I want to leave our audience with is the importance of removing the silos and understanding the importance of that interaction, because no action, no decision, has very significant consequences when water contamination occurs. And I think that there have been many examples of that over the last five to ten years in both the United States and other countries. We must be able to make timely decisions regarding water contamination events, because of the potential serious consequences to the residents who are affected.

Moderator: In other words, not to decide is to decide, as we say. We do have a call on the line from Phoenix, Arizona. Go ahead, please.

CALLER: Thank you for taking my call. My question is in regards to a reference you made to public-works workers. I'm working on an exercise which involves flooding, and one of the big things we're concerned about with public health is what personal protection equipment - above and beyond what they have currently, would be something they could use to stock up with, if they have some major flooding in their area?

Dr. Meinhardt: It's an excellent point. In my other life as an occupational-medicine physician, I found it extremely important to always remember that the people on the front line - many times public workers - may have an increased chance of getting water-related diseases because they're out there in the contaminated water, attempting to bring things back online so the rest of us have protection. Please contact me via the website. Depending on your budget and the type of disaster that we're talking about, there are certainly a variety of additional personal-protective items I would encourage you to include. In addition to training, I also want to make it clear that just providing people with equipment, I think, is really only twenty percent of preparedness. It's extremely important to make certain that those public workers understand their enhanced risk, and provide them with the kinds of clues that they need to keep their exposure risk at bay. So, please contact me and I'd be happy to run through the list that would be specific for your particular environment.

CALLER: Great. Thank you very much.

Moderator: And now we have a call from New Jersey on line three.

CALLER: Yes, hi. Other than surface water supplies, I wondered if there are any concerns of water contamination to well-water supplies - either private or public wells, when there's a flood?

Dr. Meinhardt: Absolutely. That's an extremely important point to bring up and I'm glad that you called in about it. I come from a rural area - I'm actually a Montana native, and I think it's very important that we don't forget that many, many thousands or millions of residents in the United States get their water from private or public wells. And they may certainly be contaminated and may need to have appropriate testing, and in many cases may need to have appropriate remediation efforts. It's sometimes lost when we're dealing with these massive events and we have municipal water systems that are down - we obviously are looking at the potential for millions of people affected. But it's exquisitely important for us to remember that the private wells need as much attention. It may take a very long time to test them, but they must be part of a disaster strategy, because those folks are also at potential risk for a very, very long time if their wells are contaminated. Waterborne diseases can be deadly to their families and children.

Moderator: And of course, to an extent, some of them are outside the usual public health water-system network, aren't they, in a very rural area –

Dr. Meinhardt: Maybe lost, and then may feel very threatened by the cost of testing, as well as the cost of remediating their wells or potentially having to drill a new one. But it's extremely important that healthcare providers and public health departments be thinking about those rural areas, and be thinking about providing, perhaps, education and assistance to those private well owners, because they are also at risk for very serious consequences from not only chemical contamination, but certainly the waterborne biologics that might contaminate their wells.

Moderator: Right. We have another call from Omaha, Nebraska, I believe. Go ahead, please.

CALLER: Yes, I was just wondering, would the existing water-quality standards, for example for coliforms and other types of contaminants, still apply in the event of an emergency? In other words, is there any variance that you could apply just to get people by temporarily, as far as some allowance for two or three coliforms, that type of thing in the water?

Dr. Meinhardt: Well, what you're bringing up, I think, is an extremely important point. When we have a natural disaster, a man-made accident, or if we had an act of water terrorism, you're going to need to make these decisions at the local and state level, and potentially with federal assistance, almost on an hourly basis. That's why you want that team together. If you present this and you're the water-utility person saying do you think we could get by with the following - you want to be able to make that decision with your local public health leaders, as well as your local physicians. You want to make that decision as a team, in order to determine what the appropriate next step is in your community. I always, as I do training across the country, urge people not to make these decisions on your own, because you may not be aware of all possible consequences. That includes the public health folks who might not understand what decision they may be making that would impact the water-utility folks, or a physician making a decision. It's extremely important you bring all that intellectual knowledge together and make the decision together at the table. And in some situations you may be making decisions that are outside of the realm of our normal standards, but may be critical in order to get through the disaster.

Moderator: All right. I think we have another call - we have a brief time for it - from Detroit.  Go ahead, please.

CALLER: Yes. Hello, Dr. Meinhardt. I'm a full-time emergency manager with the federal government. I was very impressed by your strategy fifteen, which talks about partnership. But I wanted to ask you about two things that seem to be a challenge. First is that users always take water for granted, so they don't necessarily want to partner when they're talking about emergency preparedness for water accidents. And secondly, it seems like some of the utility providers have a very snobbish attitude about their product, in the sense that we need them - they don't need us, because we can't live without water. Is there anybody in the nation who has benchmarked partnership with their water-utility provider?

Dr. Meinhardt: There absolutely are, and when I talk about the inconsistency of these interagency relationships across the country, I've been quite surprised. I've gone to certain states where there's an extraordinary amount of collaboration and coordination. And then in other situations there's absolutely no sitting down together at the table. Your point is absolutely important though, and I'm hoping after the floods in the Gulf region this summer, that we've finally shaken the public into understanding they can't take their water for granted. I also hope that water-utility folks, as well as everyone else, understand how important it is that we all work together. It's vital for us to prevent the kind of disasters that occurred in the Gulf next time - to sit down and work together.

Moderator: All right, Dr. Meinhardt. Thank you very much for coming back. It's been an incredibly informative hour, and it went rather quickly, I think.

Dr. Meinhardt: My pleasure.

Moderator: All right. And thank you for joining us today. We'd appreciate it if you'd fill out your evaluation forms online, at the website listed on the screen. This program will be available via archived videostreaming next week. Please check our website for more details on that. And just a reminder that other previous programs mentioned during our program today, such as Planning for the Needs of Special Populations, and Preparing for Surge Capacity, are also available on the website. We hope you'll tune in next month on March 9th, for a special ninety-minute program on Making Sense of NIMS: the National Incident Management System with Dr. Donald Sutton, who is a Training and Education Coordinator for the Colorado Department of Public Health and Environment. This program is being presented in partnership with NACCHO - the National Association of City and County Health Officials. The program will be broadcast live from ten a.m. until eleven-thirty a.m. Eastern Standard Time. We'd like to ask you to make a special effort to invite your partners from other agencies to view this program with you. I'm Peter Slocum. I'll see you next time on the University at Albany Center for Public Health Preparedness Grand Round Series.

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