1. Walkerton: Lessons Learned
Colin Mayfield, Department of Biology, University of Waterloo and United Nations University: International Network on Water, Environment and Health

2. What happened ?
Seven people died and over 2,300 became ill from Escherichia coli infections in a small town of 4,800 people.
It was caused by many factors and the mistakes of many people and agencies
The causes of this outbreak were investigated by a judicial inquiry and the persons and organizations responsible were identified.
Escherichia coli O157 H7

3. Perspective
Seven people died and over 2,300 became ill from Escherichia coli infections in a small town of 4,800 people.
It was caused by many factors and the mistakes of many people and agencies
To put this in perspective, it is equivalent to an outbreak in the Greater Toronto Area where over 1.4 million people become infected and over 4,000 die

4. The Events at Walkerton The Results The Reasons The Inquiry
Index
The Organism
The Events at Walkerton
The Results
The Reasons
The Inquiry
The Lessons
The Future
Overview

5. The Organism
THE ORGANISM
1.5 mM
Escherichia coli O157:H7

6. What is Escherichia coli O157:H7?
E. coli O157:H7 is one of hundreds of strains of the bacterium Escherichia coli. Although most strains are harmless and live in the intestines of healthy humans and animals, this strain produces a powerful toxin and can cause severe illness.
E. coli O157:H7 was first recognized as a cause of illness in 1982 during an outbreak of severe bloody diarrhea; the outbreak was traced to contaminated hamburgers. Since then, most infections have come from eating undercooked ground beef
What is E coli o157:h7
The combination of letters and numbers in the name of the bacterium refers to the specific markers found on its surface and distinguishes it from other types of E. coli.

7. Epidemiology (CDC, Atlanta)
The organism can be found on a small number of cattle farms and can live in the intestines of healthy cattle. Meat can become contaminated during slaughter, and organisms can be thoroughly mixed into beef when it is ground. Bacteria may get into raw milk.
Eating meat, especially ground beef, that has not been cooked sufficiently to kill E. coli O157:H7 can cause infection. Contaminated meat looks and smells normal.
Epidemiology
Drinking unpasteurized milk and swimming in or drinking sewage-contaminated water can also cause infection.

8. Symptoms
Symptoms
E. coli O157:H7 infection often causes severe bloody diarrhea and abdominal cramps; sometimes the infection causes non-bloody diarrhea or no symptoms. Usually little or no fever is present, and the illness resolves in 5–10 days.
In some persons, particularly children under 5 years of age and the elderly, the infection can also cause a complication called hemolytic uremic syndrome, in which the red blood cells are destroyed and the kidneys fail.
About 2%–7% of infections lead to this complication. In the United States, hemolytic uremic syndrome is the principal cause of acute kidney failure in children, and most cases of hemolytic uremic syndrome are caused by E. coli O157:H7.

9. Bottom Line?
It is a well-known organism (since 1982)
The symptoms of juvenile hemolytic uremic syndrome are often caused by this organism
10,000–20,000 cases of infection occur in the United States each year
Most illness has been associated with eating undercooked, contaminated ground beef
“Infection can also occur after drinking raw milk and after swimming in or drinking sewage-contaminated water” - CDC, Atlanta
Bottom Line ?

10. The Events at Walkerton
Well 5
Farm that was the source of the E. coli

11. Well 5 was an extremely shallow well and, when the pump was operating, water was drawn down from the surface water around the well.
When the pump was not operating, natural springs occurred in the depression around the well.
In other words there was a direct connection between the surface water and the well as it pumped from the shallow groundwater aquifer.
Well 5

12. The PUC was supposed to do that. It did not.
Well 5 - 2
Coupled with these technical issues was the issue of management and reporting of contamination events.
Reports from private laboratories to the Public Utilities Commission that showed the presence of coliforms or Escherichia coli in the drinking water did not have to be sent to the Ministry of the Environment or the Health Unit.
The PUC was  supposed to do that.  It did not.

13. Broken Loop

14. Events 1
Then the chlorination plant did not inject chlorine at the required level (it had been faulty for some time).
Levels of chlorine in the drinking water are supposed to be at or above 0.5 ppm. Documented cases are in the log books for the wells where these criteria were not met.
In addition, many readings over a long period of time were stated to be at either "0.5" or "0.7" ppm - an unlikely coincidence for all levels to be essentially identical over a long period of sampling.
Stan Koebel (the manager of the PUC) and Frank Koebel later admitted at the inquiry that the results were often fabricated and that samples sent for analysis for water quality were often from the wrong sample sites.

15. They both stated that they did not know much about coliform bacteria
Frank Koebel also stated he “got complaints” about excessive chlorination and often “dialed back” the chlorinator.
They both stated that they did not know much about coliform bacteria
A new chlorinator was supposed to be installed but was not
Then it rained
Well 5 was contaminated during a heavy rainfall in May Bacteria from a farm manure pile entered the well through overland flow and/or through transport in groundwater after percolating down through the very permeable soil to the shallow aquifer.
Since the chlorinator was not working, the E. coli O157:H7 entered the town’s water system and was distributed to everybody.
Events 2

16. The Events at Walkerton
Well 5
Farm that was the source of the E. coli

17. The number of people who became ill was approximately 2300.
In total, 174 people had presumptive laboratory evidence of E. coli O157, 167 of which were confirmed as E. coli O157:H7.
116 people were confirmed with Campylobacter species
65 patients were admitted to hospital, and of these, 27 developed hemolytic uremic syndrome.
Seven people died as a result of the outbreak.
Events 3
Health Canada Report

18. Events 4
Stan Koebel lied to the Medical Officer of Health about the presence of coliforms in the water supply after the start of the outbreak.
Only when an MoE employee deduced that the water was the problem and initiated testing and then informed the MoH did action (the “boil water advisory”) begin.

19. The Reasons Cutbacks driven by ideology PUC oversight failed
PUC members
No-one with any water system expertise, left all management and operational decisions to PUC staff
Part-time positions – Hydro concerns predominated
Summary
Government of Ontario
Cutbacks driven by ideology
No risk analysis of decisions
Ignored expert advice (including Chief Medical Officer of Health for Ontario)
PUC oversight failed
PUC Management (Stan and Frank Koebel)
Untrained
Unqualified (“grandfathered” to position)
Dishonest reporting
Attitudes to water system management
Potential loss of positions upon amalgamation
Hydro concerns predominated
40% staff decrease
Ministry of the Environment
Previous coliform problems at Walkerton (and many other places) not dealt with
Cutbacks to staff leading to lack of inspection
Privatization of laboratory analyses – no clear guidelines
Inspection, reporting and remediation processes flawed
MoE oversight, training and inspection roles failed
Health Unit
Small staff, large area to cover
Budget decrease
E. coli counts were not reported to them
Municipal water systems rated 2 to 3% of staff time

20. The Inquiry
The INQUIRY
Justice Dennis O’Connor conducted a detailed, exhaustive and extremely thorough investigation including a series of commissioned technical reports, expert witness presentations and cross-examinations, investigation and examination of all “players” (PUC, Township council, MoE and other ministries, Ontario government ministers and the Premier of Ontario, and many individuals)
He produced a Part 1 report that detailed exactly “what happened and why”.
Part II of the report followed at the end of May 2002 and consisted of recommendations to prevent similar occurrences.
Both are on the Biology 447 website

21. The Lessons We can learn many lessons from the Walkerton tragedy
THE LESSONS- Social
We can learn many lessons from the Walkerton tragedy
Social “Lessons”
Citizen awareness and involvement
Oversight of essential services
Hiring and employment practices
Community response
Health system – information and practices

22. The Lessons Regulatory “Lessons”
Monitoring is an essential prerequisite for regulation
If results are not reported to the right people, regulation cannot occur
“Toothless” or un-enforced regulations are more dangerous than none at all because of the false sense of security
Political interference, government attitudes or ideologies do have effects on regulation intensity and quality.
Sufficient funding is needed to effectively monitor and regulate
Well-informed and educated personnel are essential for monitoring/regulation

23. The Lessons Education “Lessons”
Training and frequent updating of the knowledge of personnel at all levels is essential
Those in oversight positions need to enforce this
Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:

24. The Lessons Education “Lessons”
The major cause of peptic ulcers has been known to microbiologists for many years: it is a bacterial infection of the stomach lining by Helicobacterium pylori.
Some health personnel today still quote “stress” as the major cause and prescribe antacids rather than an antibiotic
The Lessons
Education Lessons 2
Education “Lessons”
Training and frequent updating of the knowledge of personnel at all levels is essential
Those in oversight positions need to enforce this
Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:

25. The major cause of peptic ulcers has been known to microbiologists for many years: it is a bacterial infection of the stomach lining by Helicobacterium pylori.
Some health personnel today still quote “stress” as the major cause and prescribe antacids rather than an antibiotic
The Lessons
Education Lessons 3
Education “Lessons”
Training and frequent updating of the knowledge of personnel at all levels is essential
Those in oversight positions need to enforce this
Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:
26% of the people in North America think the Sun revolves around the Earth

26. The major cause of peptic ulcers has been known to microbiologists for many years: it is a bacterial infection of the stomach lining by Helicobacterium pylori
Some health personnel today still quote “stress” as the major cause and prescribe antacids rather than an antibiotic
The Lessons
Education Lessons 4
The cause of peptic ulcers has been known to microbiologists for many years: it is a bacterial infection of the stomach lining by Helicobacterium species.
Many health personnel today still quote “stress” as the major cause and prescribe antacids.
Education “Lessons”
Training and frequent updating of the knowledge of personnel at all levels is essential
Those in oversight positions need to enforce this
Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:
26% of the people in North America think the Sun revolves around the Earth
50% of the population of the USA believe that the position of stars at birth affects a person’s future
(Astrology)

27. The Lessons Education “Lessons”
Training and frequent updating of the knowledge of personnel at all levels is essential
Those in oversight positions need to enforce this
Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:
Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee.
Risk analysis and risk management is not commonly taught or known.

28. Education Lessons 6 Risk 1
Risk Perception
Activities Perceived as Higher Risk by:
United States Environmental Protection Agency (EPA)
Global warming
Indoor air pollution, including radon (high health risk)
Exposure to chemicals in consumer products (high health risk)
Surface water pollution (high ecological risk)
the Public
Chemical waste disposal
Water pollution
Chemical plant accidents
The Lessons
Education Lessons 6 Risk 1
Education
Training and frequent updating of the knowledge of personnel at all levels is essential
Those in oversight positions need to enforce this
Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:
Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee.
Risk analysis and risk management is not commonly taught or known.

29. Education Lessons 7 Risk 2
Risk Perception
Activities Perceived as Higher Risk by:
United States Environmental Protection Agency (EPA)
Global warming
Indoor air pollution, including radon (high health risk)
Exposure to chemicals in consumer products (high health risk)
Surface water pollution (high ecological risk)
the Public
Chemical waste disposal
Water pollution
Chemical plant accidents
Risk Perception
Activities Perceived as Higher Risk by:
United States Environmental Protection Agency (EPA)
Global warming
Indoor air pollution, including radon (high health risk)
Exposure to chemicals in consumer products (high health risk)
Surface water pollution (high ecological risk)
the Public
Chemical waste disposal
Water pollution
Chemical plant accidents
Education Lessons 7 Risk 2
Education
Training and frequent updating of the knowledge of personnel at all levels is essential
Those in oversight positions need to enforce this
Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:
Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee.
Risk analysis and risk management is not commonly taught or known.
Activities Perceived as Lower Risk by:
the EPA
Hazardous waste sites - active and inactive
Underground storage tanks
the Public
Indoor air pollution
Exposure to chemicals in consumer products
Global warming

30. Education Lessons 8 Risk 3
Risk Perception
Activities Perceived as Higher Risk by:
United States Environmental Protection Agency (EPA)
Global warming
Indoor air pollution, including radon (high health risk)
Exposure to chemicals in consumer products (high health risk)
Surface water pollution (high ecological risk)
the Public
Chemical waste disposal
Water pollution
Chemical plant accidents
Education Lessons 8 Risk 3
Education
Training and frequent updating of the knowledge of personnel at all levels is essential
Those in oversight positions need to enforce this
Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:
Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee.
Risk analysis and risk management is not commonly taught or known.
Activities Perceived as Lower Risk by:
the EPA
Hazardous waste sites - active and inactive
Underground storage tanks
the Public
Indoor air pollution
Exposure to chemicals in consumer products
Global warming

31. Education Lessons 9 Risk 4
Risk Perception
Activities Perceived as Higher Risk by:
United States Environmental Protection Agency (EPA)
Global warming
Indoor air pollution, including radon (high health risk)
Exposure to chemicals in consumer products (high health risk)
Surface water pollution (high ecological risk)
the Public
Chemical waste disposal
Water pollution
Chemical plant accidents
One topic where they agree !
Education Lessons 9 Risk 4
Education
Training and frequent updating of the knowledge of personnel at all levels is essential
Those in oversight positions need to enforce this
Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:
Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee.
Risk analysis and risk management is not commonly taught or known.
Activities Perceived as Lower Risk by:
the EPA
Hazardous waste sites - active and inactive
Underground storage tanks
the Public
Indoor air pollution
Exposure to chemicals in consumer products
Global warming

32. Risk Perception Overview
Education
Training and frequent updating of the knowledge of personnel at all levels is essential
Those in oversight positions need to enforce this
Glacially slow rates of knowledge transfer from the scientific and management community to the “on the ground” personnel is a serious problem. This is a problem that is almost universal:
Health and environmental issues are often of no immediate “popular” concern until problems happen. A long history of safety is no guarantee.
Risk analysis and risk management is not commonly taught or known.
Most people will accept a “one in a million” risk level of dying in a particular year except:
If it is something that is not understood or controllable (radiation, nuclear power stations, chemical spills, etc.) – then any level of risk is too high !
If it applies to them or their loved ones or family !
If it is something they understand and is controllable and they have “chosen” to do such as smoking, motorcycling, sky-diving, or driving – then they will accept a much higher (often an incredible) risk !

33. The Lessons Legal “Lessons”
Passage of good regulations is not sufficient
Enforcement of regulations and standards is often left to the discretion of fairly junior personnel
Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations.

34. The Lessons Walkerton Legal “Lessons”
Passage of good regulations is not sufficient
Enforcement of regulations and standards is often left to the discretion of fairly junior personnel
Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations.
Walkerton

35. The Lessons ENRON Walkerton Legal
Legal Lessons 3
Legal
Passage of good regulations is not sufficient
Enforcement of regulations and standards is often left to the discretion of fairly junior personnel
Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations.
ENRON
Walkerton

36. The Lessons Waste Management Inc. ENRON Arthur Andersen Inc. Walkerton
Legal Lessons 4
Legal
Passage of good regulations is not sufficient
Enforcement of regulations and standards is often left to the discretion of fairly junior personnel
Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations.
ENRON
Arthur Andersen
Inc.
Walkerton
Adelphia Inc
Global Crossings Inc.
Varnicolor (Elmira)

37. The Lessons Waste Management Inc. Exxon Valdez Love Canal ENRON
Legal Lessons 5
Exxon Valdez
Love Canal
Legal
Passage of good regulations is not sufficient
Enforcement of regulations and standards is often left to the discretion of fairly junior personnel
Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations.
ENRON
Arthur Andersen
Inc.
Walkerton
Union Carbide
Bhopal
Cryptosporidium infections from water in Australia, the US and Waterloo Region
Varnicolor (Elmira)

38. UNIROYAL Pesticide Production - Chemical Disposal
The Lessons
Waste Management
Inc.
Legal Lessons 6
Exxon Valdez
Love Canal
Legal
Passage of good regulations is not sufficient
Enforcement of regulations and standards is often left to the discretion of fairly junior personnel
Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations.
ENRON
UNIROYAL Pesticide Production - Chemical Disposal
Elmira, Waterloo
Complied with all regulations
Arthur Andersen
Inc.
Walkerton
Union Carbide
Bhopal
Cryptosporidium infections from water in Australia, the US and Waterloo Region
Varnicolor (Elmira)

39. The Lessons Legal “Lessons”
Passage of good regulations is not sufficient
Enforcement of regulations and standards is often left to the discretion of fairly junior personnel
Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations.
Often, these companies are the ones that can cause the most damage because their costs of compliance to regulations are high and so their savings by not complying are large

40. The Lessons Legal “Lessons”
Passage of good regulations is not sufficient
Enforcement of regulations and standards is often left to the discretion of fairly junior personnel
Without a significant penalty, and without strong monitoring and enforcement of regulations, some people and companies will choose to ignore the regulations.
Often, these companies are the ones that can cause the most damage because their costs of compliance to regulations are high and so their savings by not complying are large
New developments and information may make regulations obsolete or ineffective. Constant vigilance is required.

41. Scientific (research and information dissemination) “Lessons”
There is an enormous amount of new “raw” research information and it is more accessible than ever before.
Scientists are becoming more and more specialized due to this “information explosion”
Anyone who attempts to be a “generalist” has less and less knowledge about any given part of their wider expertise
This is leading to a dichotomy between these groups

42. Scientific (research and information dissemination) “Lessons”
There is an enormous amount of new “raw” research information and it is more accessible than ever before.
Scientists are becoming more and more specialized due to this “information explosion”
Anyone who attempts to be a “generalist” has less and less knowledge about any given part of their wider expertise
This is leading to a dichotomy between these groups
Research data should be translated more effectively into a form that is more accessible to the users and to the general public.
Scientists, engineers and others have to take more responsibility for wider dissemination of the meaning of their research and development work. Many are reluctant to do this.
Scientific Lessons 3

43. Those people included some microbiologists !
Scientific (research and information dissemination) “Lessons”
There is an enormous amount of new “raw” research information and it is more accessible than ever before.
Scientists are becoming more and more specialized due to this “information explosion”
Anyone who attempts to be a “generalist” has less and less knowledge about any given part of their wider expertise
This is leading to a dichotomy between these groups
Research data should be translated more effectively into a form that is more accessible to the users and to the general public.
Scientists, engineers and others have to take more responsibility for wider dissemination of the meaning of their research and development work. Many are reluctant to do this.
Scientific Lessons 5
Most of the people involved in Walkerton did not know that some forms of E. coli could kill
Those people included some microbiologists !

44. The Lessons Economic “Lessons”
We have a reasonable infrastructure of roads, sewers, water pipes, electricity, telephones and communications systems in place
General taxation has funded these infrastructure costs in the public sector
Repair costs have not been adequately funded and are now very large
These costs will have to come from increased taxes, increased cost recovery (eg - metered water supplies), downloading of costs to lower level governments or privatization
Future generations will have to pay for the repairs as well as their on-going maintenance

45. Is access to clean, safe water a “right” or is water a “commodity” ?
The Lessons
Economic Lessons
Economic “Lessons”
We have a reasonable infrastructure of roads, sewers, water pipes, electricity, telephones and communications systems in place
General taxation has funded these infrastructure costs in the public sector
Repair costs have not been adequately funded and are now very large
These costs will have to come from increased taxes, increased cost recovery (eg - metered water supplies), downloading of costs to lower level governments or privatization
Future generations will have to pay for the repairs as well as their on-going maintenance
The World Bank has a policy of requiring countries applying for funding of water projects to have their citizens pay for their water use
Is access to clean, safe water a “right” or is water a “commodity” ?

46. The Lessons
Economic Lessons
Economic “Lessons”
We have a reasonable infrastructure of roads, sewers, water pipes, electricity, telephones and communications systems in place
General taxation has funded these infrastructure costs in the public sector
Repair costs have not been adequately funded and are now very large
These costs will have to come from increased taxes, increased cost recovery (eg - metered water supplies), downloading of costs to lower level governments or privatization
Future generations will have to pay for the repairs as well as their on-going maintenance
The cost of bringing the water systems in Ontario to the level at which another Walkerton is unlikely to happen will be hundreds of millions or billions of dollars

47. Governance/Political Lessons
The Lessons
Governance/Political Lessons
Governance and Political “Lessons”
The Walkerton tragedy and inquiry highlighted:
Governance for infrastructure such as water supply
Political cost of failure versus economic cost of success
Corporate, government and individual legal liabilities
The positive effect of an rigorous, impartial and complete judicial inquiry into these kinds of events

48. Governance/Political Lessons
The Lessons
Governance/Political Lessons
Governance and Political “Lessons”
The Walkerton tragedy and inquiry highlighted:
Governance structure for infrastructure such as water supply
Political cost of failure versus economic cost of success
Corporate, government and individual legal liabilities
The positive effect of an rigorous, impartial and complete judicial inquiry into these kinds of events
The Walkerton Inquiry was wide-ranging and comprehensive. It allowed the citizens of Walkerton to see that all avenues were being investigated, all experts were being consulted and no-one was allowed to hide what had happened.
It was accompanied by detailed investigations that included the examination of thousands of documents and interviewing hundreds of people.

49. The Future Other issues: Heightened public awareness of vulnerability
New Technologies (eg - membrane filtration for water, household water purification units)
Factory farms and manure disposal practices and regulation
“Right to farm”
Sewage sludge disposal practices and regulation
Pharmaceutical products in groundwater supplies
Groundwater protection
Rural versus urban water contamination

50. Have the Lessons been learned ?
Yes – the technical aspects were already known by the people and companies in the water treatment and supply business.
The financial and political means to upgrade and inspect water treatment systems were put in place.
It is unlikely that there will be a repeat of Walkerton in Ontario.
Have the Lessons been learned ?

51. Have the Lessons been learned 2 ?
Yes – the technical aspects were already known by the people and companies in the water treatment and supply business.
The financial and political means to upgrade and inspect water treatment systems were put in place.
It is unlikely that there will be a repeat of Walkerton in Ontario.
But it was a series of unlikely events that caused the problem in the first place !
Have the Lessons been learned 2 ?

52. Have the lessons been learned ?
Yes – the technical aspects were already known by the people and companies in the water treatment and supply business.
The financial and political means to upgrade and inspect water treatment systems were put in place.
It is unlikely that there will be a repeat of Walkerton in Ontario.
But it was a series of unlikely events that caused the problem in the first place !
North Battleford
After the Cryptosporidium outbreaks in Milwaukee, the Region of Waterloo and other places, it happened again in North Battleford, Saskatchewan. About 7,000 people were infected
Their water intake was downstream from the sewage outlet system, the chlorinator was working, but Cryptosporidium is resistant to chlorination.

53. River/Sewage/Water Treatment Plant
Sewage Treatment
River/Sewage/Water Treatment Plant
Water treatment
Flow direction

54. The Report of the Inquiry into North Battleford maybe says it all:
Summary of Inquiry NB
The Report of the Inquiry into North Battleford maybe says it all:
“As the commission counsel stated at one point in the hearings, there were no villains in this story. There was simply a great deal of indifference to the public health safety aspects of drinking water on the part of the city who had the responsibility to produce potable water, and on the part of the Saskatchewan Environment and Resource Ministry who had the mandate to regulate it”

55. BLANK PAG E

56. Addenda 1. Summary conclusions of Part 1 Walkerton Inquiry
2. Helicobacterium pylori and peptic ulcers
3. Web site addresses

57. Summary of Walkerton Inquiry
Full text at -
Summary of Walkerton Inquiry
Part One: A Summary Report of the Walkerton Inquiry:
The Events of May 2000 and Related Issues
In May 2000, Walkerton’s drinking water system became contaminated with deadly bacteria, primarily Escherichia coli O157:H7.1 Seven people died, and more than 2,300 became ill. The community was devastated. The losses were enormous. There were widespread feelings of frustration, anger, and insecurity.
The tragedy triggered alarm about the safety of drinking water across the province. Immediately, many important questions arose. What actually happened in Walkerton? What were the causes? Who was responsible? How could this have been prevented? Most importantly, how do we make sure this never happens again?

58. Summary of Conclusions Page 1
Summary Page 1
Seven people died, and more than 2,300 became ill. Some people, particularly children, may endure lasting effects.
• The contaminants, largely E. coli O157:H7 and Campylobacter jejuni, entered the Walkerton system through Well 5 on or shortly after May 12, 2000.
• The primary, if not the only, source of the contamination was manure that had been spread on a farm near Well 5. The owner of this farm followed proper practices and should not be faulted.
• The outbreak would have been prevented by the use of continuous chlorine residual and turbidity monitors at Well 5.
• The failure to use continuous monitors at Well 5 resulted from shortcomings in the approvals and inspections programs of the Ministry of the Environment (MOE). The Walkerton Public Utilities Commission (PUC) operators lacked the training and expertise necessary to identify either the vulnerability of Well 5 to surface contamination or the resulting need for continuous chlorine residual and turbidity monitors.

59. Summary of Conclusions – Page 2
Summary Page 2
• The scope of the outbreak would very likely have been substantially reduced if the Walkerton PUC operators had measured chlorine residuals at Well 5 daily, as they should have, during the critical period when contamination was entering the system.
• For years, the PUC operators engaged in a host of improper operating practices, including failing to use adequate doses of chlorine, failing to monitor chlorine residuals daily, making false entries about residuals in daily operating records, and misstating the locations at which microbiological samples were taken. The operators knew that these practices were unacceptable and contrary to MOE guidelines and directives.
• The MOE’s inspections program should have detected the Walkerton PUC’s improper treatment and monitoring practices and ensured that those practices were corrected.
• The PUC commissioners were not aware of the improper treatment and monitoring practices of the PUC operators. However, those who were commissioners in 1998 failed to properly respond to an MOE inspection report that set out significant concerns about water quality and that identified several operating deficiencies at the PUC.
• On Friday, May 19, 2000, and on the days following, the PUC’s general manager concealed from the Bruce-Grey-Owen Sound Health Unit and others the adverse test results from water samples taken on May 15 and the fact that Well 7 had operated without a chlorinator during that week and earlier that month. Had he disclosed either of these facts, the health unit would have issued a boil water advisory on May 19, and 300 to 400 illnesses would have been avoided.

60. Summary of Conclusions – Page 3
Summary Page 3
• In responding to the outbreak, the health unit acted diligently and should not be faulted for failing to issue the boil water advisory before Sunday, May 21. However, some residents of Walkerton did not become aware of the boil water advisory on May 21. The advisory should have been more broadly disseminated.
• The provincial government’s budget reductions led to the discontinuation of government laboratory testing services for municipalities in In implementing this decision, the government should have enacted a
regulation mandating that testing laboratories immediately and directly notify both the MOE and the Medical Officer of Health of adverse results. Had the government done this, the boil water advisory would have been issued by May 19 at the latest, thereby preventing hundreds of illnesses.
• The provincial government’s budget reductions made it less likely that the MOE would have identified both the need for continuous monitors at Well 5 and the improper operating practices of the Walkerton PUC.
• The Part 1 report contains some recommendations directed toward ensuring the safety of drinking water in Ontario. However, the majority of my recommendations in that respect will be in the Part 2 report of this Inquiry.

61. Helicobacterium pylori
Helicobacter pylori
Helicobacterium pylori
Peptic ulcer disease is a common clinical ailment, once thought to be caused by oversecretion of acid and pepsin, an enzyme of the stomach that promotes digestion by breaking down proteins. Researchers have found, however, that although the injury caused by acid and pepsin is necessary for the formation of ulcers, acid secretion levels of the majority of patients with gastric or duodenal ulcers are normal.
An ulcer is now known to be the result of an imbalance between aggressive and defensive mechanisms in the stomach and duodenum. Part of that imbalance can be attributed to infection by H. pylori.
Humans are the only known host of Helicobacter pylori. Its prevalence in healthy people increases with age to over 50% in people over the age of 60. Studies have shown that Blacks are more susceptible to infection than are Whites, and incidents of infection increase with decreasing socioeconomic status. Evidence of H. pylori infection in families, prisons, and nursing homes suggest that H. pylori is spread by close personal contact. However, the exact mechanism for transmission of the bacteria is not well understood.

62. Web Sites The full part 1 Walkerton Inquiry Report can be found at:
As well as at the Walkerton Inquiry Web Site at:
Background materials on E. coli and Walkerton:
Risk Analysis – “Mini-course” and overview: