1. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Center for Public Health Preparedness Grand Rounds Assessing the Threat of Water Contamination: Waterborne Disease, Water Pollution and Water Terrorism Patricia L. Meinhardt, MD, MPH, MA Executive Medical Director Center for Occupational and Environmental MedicineArnot Ogden Medical Center Elmira, New York

2. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Thanks to our Sponsors: University at Albany School of Public Health Centers for Disease Control and Prevention Association of Schools of Public Health

3. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Viewer Call-In Phone: 800-452-0662 Fax: 518-426-0696

4. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Evaluations Please complete and return your evaluations to the University at Albany School of Public Health Center for Public Health Preparedness. Your feedback is invaluable to this program. Thank you!

5. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Evaluations can be submitted online at: http://www.ualbanycphp.org/eval /cphpeval.cfm?ID=19 or they can be mailed to us.

6. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Center for Public Health Preparedness For more information please contact us or log on to our website. 518-486-7921 www.ualbanycphp.org

7. Patricia L. Meinhardt, MD, MPH, MA www.WaterHealthConnection.org

8. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE How real is the terrorist threat to US water supplies?

9. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE

13. Contamination of water reserves by either chemical compounds, infectious pathogens, or radiologic agents… May affect the health of millions of Americans. May lead to significant morbidity and mortality especially in vulnerable populations at increased risk of disease.

14. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Partnership Triad Protecting Drinking Water and Public Health Drinking Water Professionals Public Health Community Medical Community Patients Water Consumers

15. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Local public health departments play a critical role in water protection and security since they… May be the first to recognize intentional water contamination Will need to notify water utilities promptly Will provide critical initial data to state and federal public health agencies

16. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE DRINKING WATER CONTAMINATION RECREATIONAL WATER POLLUTION "SPECIAL USES" WATER CONTAMINATION INTENTIONAL WATER CONTAMINATION OR WATER TERRORISM Causes of Waterborne Disease in US

17. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE DRINKING WATER CONTAMINATION Microbial contamination of drinking water animal or human sewage pathogens inadequately treated source water resistant pathogens to treatment technologies

18. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Chemical contamination of drinking water agricultural run-off leakage from underground storage tanks industrial discharges and chemical spills erosion of natural deposits - arsenic, lead, etc.

19. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE  According to recent EPA report, as many as 40% of US beaches, rivers, estuaries and lakes may be polluted with microbial or chemical contaminant.  Recreational water outbreaks have been reported in swimming and wading pools, lakes and ponds, rivers and canals, decorative fountains, hot tubs and springs.  During 1999-2000 reporting period, 59 recreational waterborne outbreaks were reported with 2093 illnesses and four deaths in the U.S. RECREATIONAL WATER POLLUTION

20. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Waterborne Outbreaks by WATER SOURCE Modified from: MMWR, Surveillance for Waterborne Disease Outbreaks United States, 1999-2000 Spring 5.3% Well 68.4% Surface water 18.4% Irrigation system 7.9% DRINKING WATER

21. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Waterborne Outbreaks by ETIOLOGIC AGENT Bacterial 23.1% Parasitic 17.9% Viral 10.3% Chemical 5.1% Unidentified 43.6% DRINKING WATER

22. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Waterborne Outbreaks by DEFICIENCY Untreated Surface water 2.6% Miscellaneous 15.4% Distribution system 15.4% Treatment deficiency 23.1% DRINKING WATER Untreated Groundwater 43.6%

23. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Water may represent a potential target for terrorist activity with contamination of US water supplies as part of an effort to damage our national infrastructure. Intentional Water Contamination

24. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Possible scenarios include: community-wide waterborne disease outbreaks or a cluster of water- related cases from either biological, chemical or radiological terrorist agents.

25. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE WMD Agents with Potential for Dispersal in Water Anthrax Brucellosis Cholera C. perfringens Glanders Bacterial Pathogens Melioidosis Plague Salmonella Shigellosis Tularemia

26. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Parasitic Pathogens Cryptosporidiosis Viral pathogens Hepatitis A Smallpox Viral Encephalitides Viral Hemorrhagic fevers Rickettsial Pathogens Psittacosis Q Fever Typhus

27. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Bacterial Biotoxins Clostridium botulinum toxins Clostridium perfringens toxins Staphylococcus enterotoxin B Mycotoxins Aflatoxin T-2 mycotoxin Anatoxin A Microcystins

28. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Bacterial Biotoxins Clostridium botulinum toxins Clostridium perfringens toxins Staphylococcus enterotoxin B Mycotoxins Aflatoxin T-2 mycotoxin Anatoxin A Microcystins

29. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Plant and Algae-Derived Biotoxins Ricin Marine Biotoxins Saxitoxin Tetrodotoxin

30. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Nerve Agents G agents (Tabun, Sarin, Soman) V agents (VX) Blood Agents Cyanide Compounds Arsine Compounds Skin Blistering Agents Lewisite Nitrogen Mustards Incapacitating Agents CNS Depressants (BZ) CNS Stimulants (LSD)

31. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Pesticides Dioxins, furans, PCBs Explosive nitro compounds and oxidizers Ammonium nitrate combined with fuel oil Industrial and Agricultural Compounds

32. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Flammable industrial gases, liquids, and solids cyanides Nitriles Corrosive industrial acids and bases nitric acid sulfuric acid

33. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Internal exposure due to ingestion of contaminated food and water Internal contamination through skin or wound absorption or deposition from contact with contaminated material including water Internal Contamination from Water Exposure

34. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Diagnostic Challenges to Recognizing Water Terrorism Many WMD agents display a significantly different clinical picture when the route of exposure is ingestion. Many of the signs and symptoms of water- related disease are non-specific and mimic more common medical disorders.

35. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Obtaining accurate exposure histories from patients who may have been exposed to waterborne agents can be difficult and challenging. The majority of WMD agents that may be used during intentional contamination of water supplies are not unique to water.

36. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Possible Points of Contamination of U.S. Water From Acts of Terrorism Upstream of a community water supply system Community water treatment plant Post-treatment water distribution system

37. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Building water tanks, cisterns, individual storage tanks Bottled water production, food processing, commercial water Contamination of recreational waters (swimming pools, etc.)

38. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE “Impossible epidemiology” with waterborne diseases diagnosed in a community not previously encountered Localized disease epidemics in a specific neighborhood possibly indicating contamination of post- treatment water Epidemiologic Indicators of Possible Water Terrorism

39. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Waterborne disease at a single location (school, hospital, nursing home) with rare pathogen Waterborne disease presenting in a community during an unusual time of the year or found in a community where the normal vector of transmission is absent

40. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Local health departments play a critical role in protecting water supplies and must promptly notify water utilities of any possible penetration of water protection and water treatment procedures. PUBLIC HEALTH PRACTITIONERS must embrace the fact that … Critical Role of Public Health Departments

41. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE WORKING WITH NEW PARTNERS IS IMPERATIVE! These new partnerships need to include local water utilities and water quality specialists. PUBLIC HEALTH PRACTITIONERS must embrace the fact that …

42. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Physician On-Line Reference Guide (WaterHealthConnection.org) Created to assist the medical and PUBLIC HEALTH community recognize and manage waterborne disease and the health effects of water contamination from either natural OR intentional contamination of water. Recognizing Waterborne Disease and the Health Effects of Water Pollution

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44. A Physician On-Line Reference Guide (WaterHealthConnection.org) New Section – Physician Preparedness for Acts of Water Terrorism Peer-review by leading terrorism experts from public health, medical academia and military medicine Recognizing Waterborne Disease and the Health Effects of Water Pollution

45. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE The new public health challenges facing all of us today include protecting water resources from both natural and intentional contamination. Collaboration and partnership between the drinking water community and the public health and medical community is the key to any successful effort to ensure our nation’s safe drinking water and protect our community’s public health. Funding provided by EPA grant # 83053501 Conclusions © 2000 - 2003 Patricia L. Meinhardt, MD, MPH, MA and Arnot Ogden Medical Center. All Rights Reserved.

46. CENTER FOR OCCUPATIONAL AND ENVIRONMENTAL MEDICINE University at Albany School of Public Health Center for Public Health Preparedness For more information please contact us or log on to our website. 518-486-7921 www.ualbanycphp.org