Drinking Water 

Information 

for Health 

Care Providers

Supplemental Materials:

• Accreditation, Designation, and 

Disclosure Statements and Learner 

Participation

• How to Apply for Continuing 

Education Credit

• Objectives 

• Key Concepts 

• Drinking Water Resources

• Additional Resources for Health 

Professionals

• Acknowledgements
Contents

Accreditation, Designation, and Disclosure 

Statements and Learner Participation . . . . . 1

How to Apply for Continuing 

Education Credit . . . . . . . . . . . . . . . . . . . . . 4

Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Drinking Water Resources . . . . . . . . . . . . . . . . 15

Additional Resources for Health

 Professionals. . . . . . . . . . . . . . . . . . . . . . . 20

Acknowledgements . . . . . . . . . . . . . . . . . . . . . 23
1

Accreditation, Designation, 

and Disclosure Statements 

and Learner Participation 

The educational activity was developed by the 

Centers for Disease Control and Prevention 

(CDC) and the United States Environmental 

Protection Agency (EPA).

Use of trade names or commercial sources is 

for informational purposes only and does not 

constitute an endorsement by the United States 

Department of Health and Human Services, the 

Public Health Service, or EPA.

Views expressed by guest participants are not 

necessarily the views of the CDC or EPA. 

This activity has been planned and implemented 

in accordance with the Essential Areas and 

Policies of the Accreditation Council for 

Continuing Medical Education (ACCME) through 

the joint sponsorship of the CDC and EPA. The 

CDC is accredited by the ACCME to provide 

Continuing Medical Education for physicians. 

The CDC designates this educational activity 

for 1.25 Category 1 credit toward the American 

Medical Association Physician’s Recognition 

Award. Each physician should claim only those 

credits that he or she actually spent in the activity. 
2

This activity for 1.2 Contact Hours is provided 

by the CDC, which is accredited as a provider of 

Continuing Education in Nursing by the American 

Nurses Credentialing Center’s Commission on 

Accreditation.

The CDC has been approved as an Authorized 

Provider of Continuing Education and Training 

programs by the International Association for 

Continuing Education and Training and awards 

0.1 Continuing Education Units.

The CDC is a designated provider of Continuing 

Education Contact Hours in Health Education by 

the National Commission for Health Education 

Credentialing, Inc. This program is a designated 

event for the Certified Health Education Specialist 

to receive 1.0 Category I Contact Hour in Health 

Education, CDC provider number GA0082.

The CDC and our presenters wish to disclose they 

have no financial interests or other relationships 

with the manufacturers of commercial products, 

suppliers of commercial services, or commercial 

supporters of this Continuing Education activity.

Presentations will not include any discussion of 

the unlabeled use of a product or a product under 

investigational use. 

Viewers may participate in the learning 

experience by emailing questions and comments 

to the organizations and associations listed in the 
3

Resources sections of this booklet, and by using 

their websites.

CE credit is available only through CDC/ATSDR’s 

website, “Training and Continuing Education 

OnLine,” at www.phppo.cdc.gov/phtnonline. See 

the instructions on the following page to learn 

how to register for credits.

The origination date of this educational activity is 

May 13, 2004. Continuing Education Credit for 

these Enduring Materials will expire on May 12, 

2007.

CDC Continuing Education Activity Numbers: 

VHS format: VC 0070

DVD format: DV 0001 
4

How to Apply for Continuing 

Education Credit

Continuing Education (CE) Credits are available 

for various professions through CDC/ATSDR’s 

Training and Continuing Education OnLine 

System based on 62 minutes of instruction (1.25 

CME, 1.2 CNE, .1 CEU, 1.0 CECH). 

Follow these 4 easy steps to obtain CE Credit:

1. Go to the Training and Continuing Education 

OnLine Website (www.phppo.cdc.gov/

phtnonline) OR link to the site from 

www.epa.gov/safewater/healthcare. If you 

have never used this system, you will 

need to create a Profile and establish a 

login ID and password. At the home page, 

www.phppo.cdc.gov/phtnonline, click on New 

Participant and follow the prompts.)

2. One you have created a Profile go to the 

home page of www.phppo.cdc.gov/phtnonline

and click on Participant Login. When the 

yellow box appears, put in your login and 

password. It will lead you to a Participant 

Services page with 4 icons that will allow you 

to move about in the system as you wish.

3. Click on the Search and Register icon and 

register for this particular course so the 

system knows what to give you credit for. You 

can search by 3 different options: using the 
5

title, “Tap Into Prevention: Drinking Water 

Information for Health Care Providers,” or 

using the course number VC 0070 or DV 

0001, or using the key words “drinking 

water.”

4. Return to the “icon” page by looking to the 

left of the screen in the gray shaded area 

and click on Participant Services. Click on 

the Evaluation and Tests icon and follow the 

prompts to complete the evaluation. The 

system will then give you an opportunity to 

print out your certificate.
6

Objectives

After watching this video, you will be able to:

• Name four health problems related to 

contaminants in drinking water

• Identify the types of patients most sensitive to 

each health problem

• Describe how contaminants can enter 

drinking water supplies

• Identify the treatment methods that remove 

the contaminants 

• List clinical findings that should prompt 

reporting suspicion of a waterborne disease to 

the local health department

• Describe how patients can learn about the 

quality of their drinking water

• Describe the role of health care providers in 

a public health network that identifies and 

responds to waterborne illness

• List resources for further information on 

drinking water and health
7

Key Concepts

The following information represents some 

contaminants to which certain patients may be 

particularly sensitive. 

Cryptosporidium parvum. Cryptosporidium 

parvum is a pathogen found in human and animal 

fecal waste. It can enter the rivers, lakes and 

streams and rarely, ground water that contribute 

to drinking water supplies. Because of it’s small 

size and composition, it is resistant to typical 

filtration and disinfection methods—though 

EPA has tightened its standards in recent years 

requiring public water systems specifically to 

address this contaminant.

• Exposure to Cryptosporidium parvum in 

drinking water may cause gastrointestinal 

problems, such as diarrhea, vomiting, and 

cramps. Patients whose immune systems 

are weakened by AIDS, chemotherapy, 

a recent transplant or other reasons are 

most vulnerable. Diarrhea and vomiting 

may cause infants and the frail elderly to 

become dehydrated more quickly. In most 

healthy adults and children, the problems 

are temporary. Other, more common 

routes of exposure to this pathogen are 

food, unsanitary diaper-changing practices, 

person-to-person-contact, and swimming in 

contaminated water.
8

• Suggested interventions: Sample stools 

more frequently. Include questions on water 

sources for patients with diarrhea. Those 

with questionable water sources require 

further investigation. Most standard ova and 

parasite cultures do not automatically test 

for Cryptosporidium. Be sure to specifically 

request an acid-fast fluorescent test.

Escherichia coli or E. coli. E. coli is a type 

of fecal coliform bacteria commonly found in the 

intestines of animals and humans. The presence 

of E. coli in water is a strong indication of recent 

sewage or animal waste contamination. Sewage 

may contain many types of disease-causing 

organisms. Although most strains of E. coli are 

harmless and live in the intestines of healthy 

humans and animals, a particular strain, E. coli 

0157:H7, produces a powerful toxin and can 

cause severe illness. 

• Most infections of E. coli O157:H7 are 

believed to have come from eating 

undercooked ground beef. However, some 

have been waterborne, and people have 

become sick after drinking contaminated 

water.

• Infection by E. coli 0157:H7 is characterized 

by severe bloody diarrhea and abdominal 

cramps, although sometimes the infection 

causes non-bloody diarrhea, often with 

no fever. In some people, particularly 

children under 5 years of age and the 
9

elderly, the infection can also cause 

a life-threatening complication called 

hemolytic uremic syndrome, in which 

the red blood cells are destroyed and the 

kidneys fail. Hemolytic uremic syndrome is 

usually treated in an intensive care unit, and 

blood transfusions and kidney dialysis are 

often required. 

• Suggested interventions: Encourage patients 

(or their parents) to have household well 

water tested annually for nitrates and 

bacteria by a state-certified laboratory. If a 

patient’s well tests positive for E. coli, people 

in the household should not drink the water 

without boiling it for at least one minute 

at a rolling boil—longer if they live at high 

altitudes. The well may also be disinfected 

according to procedures recommended by 

the local health department. Water must be 

monitored periodically after disinfection to 

make certain the problem does not recur. 

If contamination is a recurring problem, 

patients should investigate the feasiblity 

of drilling a new well or installing a pointof-entry disinfection unit using chlorine, 

ultraviolet light, or ozone.

Disinfectants and Disinfection Byproducts 

(DBPs). Disinfectants, while effective in 

controlling many microorganisms, react with 

matter in water to form DBPs. Unchlorinated 

private well water is unlikely to contain any DBPs. 
10

• While health effects from exposure to 

disinfectants and DBPs vary by contaminant, 

some epidemiological studies have shown 

a link between bladder, rectal, and colon 

cancers and DBP exposure. Additionally, 

human epidemiological studies report an 

association between chlorinated drinking 

water and reproductive and developmental 

endpoints such as spontaneous abortion, 

neural tube defects, pre-term delivery, 

intrauterine growth retardation, and low 

birth weight. In August 2003, EPA proposed 

measures beyond those already required for 

public water systems.

• Suggested interventions: Drinking plenty of 

water from a safe source during pregnancy 

is important. If your patients’ public water 

system has notified customers of a DBP 

violation, follow instructions from the public 

water system. For example, your patients 

might want to consider alternatives to tap 

water during pregnancy. 

Lead. Paint chips and dust from lead paint in 

old buildings are the primary routes of children’s 

exposure to lead, but EPA estimates that up to 

20 percent of a person’s background exposure 

may be due to lead in drinking water—and the 

percentage is higher for infants drinking formula 

mixed with contaminated drinking water. Lead 

may be present in drinking water because of 

corrosion of household plumbing systems; erosion 
11

of natural deposits. In some communities, lead 

service lines can also contribute to high levels of 

lead in drinking water.

• In infants and young children, 

continuous exposure to high levels of 

lead may result in delays in physical 

or mental development, deficits 

in attention span, and learning 

disabilities. 

• For adults, such exposure may result in 

kidney problems or high blood pressure.

• Suggested interventions: Look for symptoms 

of lead poisoning in children, and test 

infants’ blood lead levels. If a child’s blood 

lead level is high, consider lead in tap water 

as a possible factor, in addition to lead 

paint exposure. Encourage patients to have 

drinking water tested for lead in homes, 

schools, and day care centers by a statecertified laboratory. Encourage local schools 

and day care centers to test their drinking 

water outlets for lead.

• Use only cold water for drinking, cooking, 

and especially making baby formula. It’s 

important to consider that foods that absorb 

all of the water in the pot, such as rice and 

dried beans, will also absorb all of the lead 

that is in the cooking water. Soups made or 

mixed with water will also contain any lead 

that’s in the water. Foods cooked in water 
12

and then drained, such as pasta, meat, or 

vegetables, also absorb some lead from the 

water.

• If lead levels in drinking water are high, 

consider alternatives to using boiled tap 

water in baby formula.

• Information and brochures are available 

from the National Lead Information Center, 

(800) 424-LEAD [5323], www.epa.gov/lead/

nlic.htm

Nitrates and Nitrites. Nitrates may run off 

or percolate into water sources from excessive 

fertilizer use and animal waste; leaching from 

improperly constructed or maintained septic 

tanks, cesspools, sewage; or erosion of natural 

deposits. 

• Exposure to nitrates in drinking water at 

levels above the drinking water standard 

may result in methemaglobinemia, 

or “blue baby syndrome” in infants 

under six months. Blue baby syndrome 

is life-threatening without immediate 

medical attention. Infants most likely to 

get methemoglobinemia are those who are 

already sick and consume food that is high 

in nitrates, such as spinach, broccoli and 

cured meats, and drink formula mixed with 

water that is high in nitrates. 
13

• Possible interventions: Encourage patients to 

have household well water tested annually 

for nitrates and bacteria by a state-certified 

laboratory, especially those caring for infants 

and expectant parents and grandparents. 

If water has high nitrate levels, consider 

alternatives to using boiled tap water in baby 

formula. Boiling water only increases nitrate 

concentrations.

Drinking Water Security. Events of September 

11, 2001, have brought into focus the possibility 

of intentional contamination of drinking water and 

wastewater infrastructure. Doctors, nurses, and 

others in primary care would likely be the first to 

observe unusual illness patterns or disease trends 

resulting from intentional biological or chemical 

contamination.

“Recognizing Waterborne Disease and the Health 

Effects of Water Pollution: A Physician On-line 

Reference Guide,” by Patricia L. Meinhardt, 

MD, MPH, MA, includes a section, “Physician 

Preparedness for Acts of Water Terrorism.”

It is available at WaterHealthConnection.org.
14

Recognize, Report, and Prevent 

Waterborne Illness

✔ Report suspicion of waterborne illness to your 

local health department.

✔ Take an environmental health history that 

includes, “What is the source of drinking 

water?”

✔ Familiarize yourself with your patients water 

supply. Annual water quality reports are a 

good first source of information on local 

public water systems. Household well owners 

are responsible for making sure their wells are 

tested regularly and maintained properly. A 

free booklet, “Drinking Water from Household 

Wells,” is available at www.epa.gov/safewater/

privatewells/booklet/index.html.
15

Drinking Water Resources

EPA Office of Ground Water and 

Drinking Water 

Together with states, tribes, and our many 

partners, the Office of Ground Water and 

Drinking Water protects public health by ensuring 

safe drinking water and protecting ground water. 

EPA’s Safe Drinking Water Hotline provides 

information about drinking water and ground 

water protection programs authorized under the 

Safe Drinking Water Act. (800) 426-4791

www.epa.gov/safewater

CDC Division of Parasitic Diseases

The mission of the division is to prevent and 

control parasitic diseases in the United States and 

throughout the world and to increase survival 

of children in developing countries, through 

surveillance and by conducting laboratory and 

epidemiological research.

www.cdc.gov/ncidod/dpd/healthywater

Home Water Testing

Your state Certification Officer can provide a list 

of laboratories certified to test for contaminants in 

drinking water. 

www.epa.gov/safewater/faq/sco.html
16

Household Wells

Home*A*Syst

Provides information to help farmers and rural 

residents assess pollution risks and develop 

management plans to meet their unique needs.

www.wisc.edu/farmasyst

Wellcare® Hotline 

(888) 395-1033

Through wellcare®, the Water Systems Council 

provides rural well owners, other technical 

assistance providers, water system operators, and 

community leaders important information and 

training on how to properly design, operate and 

manage well-based systems.

www.watersystemscouncil.org/wellcare

DrinkWellTM Well Water Testing

Underwriters Laboratories’ well testing service 

also has a nurse call center and provides 

sources of information. For questions regarding 

ordering, sample collection and shipping, call 

888-503-5544. www.uldrinkwell.com

National Ground Water Association

This National Ground Water Association’s 

Wellowner web site offers a variety of 

information relating to ground water and private 

water well systems. www.wellowner.org
17

Home Water Treatment Units

Water Quality Association

The Water Quality Association is a not-for-profit 

international trade association representing the 

household, commercial, industrial, and small 

community water treatment industry.

www.wqa.org

NSF International

NSF International’s Home Water Treatment 

Devises web page includes information on 

selecting and using water treatment devices.

www.nsfconsumer.org/water/dw_treatment.asp

Underwriters Laboratories

Underwriters Laboratories tests and certifies home 

water treatment units to ensure they meet national 

standards. www.ul.com/water

Bottled Water

International Bottled Water Association

This trade association requires members to adhere 

to its model code, in addition to meeting federal 

requirements for bottled water.

www.bottledwater.org

NSF International

NSF International tests bottled water products 

for compliance with federal guidelines and lists 

bottled water companies certified through its 

voluntary certification program.

www.nsfconsumer.org/water/bottled_water.asp
18

Protecting Drinking Water Sources

EPA’s Source Water Protection Program

EPA has information on preventing contamination 

of streams, rivers, lakes and underground aquifers 

that supply private wells and public drinking water.

www.epa.gov/safewater/protect.html

Groundwater Foundation

The Groundwater Foundation educates and 

motivates people to care for and about ground 

water through water festivals and other activities. 

Its Groundwater Guardian program encourages 

communities to begin and enhance ground water 

awareness and protection activities.

www.groundwater.org

American Ground Water Trust

This educational organization protects ground 

water and promotes resource sustainability; 

communicates the value of ground water; 

showcases science and technology solutions; 

increases awareness; and facilitates stakeholder 

participation in water resource decisions.

www.agwt.org

Ground Water Protection Council

The Ground Water Protection Council is a 

national association of state ground water 

and underground injection control agencies 

whose mission is to promote the protection and 

conservation of ground water resources for all 
19

beneficial uses, recognizing ground water as a 

critical component of the ecosystem. 

www.gwpc.org

National Ground Water Association

The National Ground Water Association’s mission 

is to enhance the skills and credibility of all 

ground water professionals, develop and exchange 

industry knowledge and promote the ground 

water industry and understanding of ground water 

resources. www.ngwa.org

Water Systems Council

The Water Systems Council is a national nonprofit organization, dedicated to promoting the 

wider use of wells as modern and affordable safe 

drinking water systems and to protect ground 

water resources. www.watersystemscouncil.org
20

Additional Resources for 

Health Professionals

This list is not meant to be exhaustive, but includes 

opportunites for further continuing education on 

drinking water and resources on environmental 

health.

“Recognizing Waterborne Disease and the Health 

Effects of Water Pollution,” an online reference 

guide; up to 22 Continuing Medical Education 

credits and continuing education credits for other 

professions are sponsored by American College of 

Preventive Medicine. By Patricia Meinhardt, MD, 

MPH, MA Includes a repository of information on 

how to detect biological and chemical weapons 

exposure and respond appropriately. 

www.waterhealthconnection.org

“Waterborne Disease and Water Pollution: What 

Every Physician in Your Community Needs to 

Know.” This American College of Preventive 

Medicine Institute contains 10 presentations by 

various physicians and water professionals in 

streaming video and audio. Speakers provide a 

clinical overview of diagnosis and management 

of waterborne disease and health effects of 

water pollution, as well as strategies for risk 

communication to discuss these environmental 

health issues with patients. The sessions also 

address challenges facing the water utility 
21

community, tasked with providing safe drinking 

water in America.

www.acpm.org/ehealth/waterborne.htm

Drinking Water and Disease: What Every Health 

Care Provider Should Know, Physicians for Social 

Responsibility

www.envirohealthaction.org/upload_files/

dwprimer.pdf

“Environmental Health and Nursing,” a 

developing educational series designed to 

assist nurses integrating environmental health 

knowledge and skills in professional practice 

through distance learning. CEU and graduate 

credits available.

University of Minnesota School of Public Health, 

http://mclph.jawshotel.umn.edu/pubh7201

University of Maryland School of 

Nursing EnviRN Website

A Virtual Resource for Environmental 

Health and Nursing

www.envirn.umaryland.edu

EnviRN’s gateway to an array of 

resources including multimedia content: 

envirn.umaryland.edu/resources/resources.htm

Environmental Health and Nursing Practice, by 

Barbara Sattler, RN, DrPH, and Jane Lipscomb, 

RN, PhD, FAAN, Editors, www.springerpub.com/

store/page 4282_6.html
22

National Environmental Education and Training 

Foundation Health Publications

Includes links to information for health 

care providers on pesticides, ranging from 

national strategies to medical and nursing 

practice guidelines. www.neetf.org/Health/

publications.sthm
23

Acknowledgements

Co-authors:

John Balbus, MD, MPH, Director, 

Environmental Health Program, 

Environmental Defense, Washington, 

DC; Founding Director, Center for Risk 

Science and Public Health, George 

Washington University Medical Center

Vince Clews, Screenwriter, Baltimore, MD

Sherri Umansky, Environmental Protection 

Specialist, Office of Ground Water and 

Drinking Water, U.S. Environmental 

Protection Agency, Washington, DC

Narrators:

John Balbus, MD, MPH

Paul Anthony, Actor, Chevy Chase, MD

Featured Experts: 

Milwaukee 

Paul Bierdrzycki, Manager of Disease Control, 

City of Milwaukee Health Department

*Kathleen Blair, RN, Epidemiologist, 

City of Milwaukee Health Department

Mary Busalacchi, HIV Nurse Clinician, 

Milwaukee

Lon Couillard, Water Quality Manager, 

Milwaukee Water Works
24

Ian Gilson, MD, Internist, Milwaukee

Karen Sue Kehl, PhD, Associate Professor and 

Section Director, Microbiology, Medical 

College of Wisconsin; Technical Director 

of Microbiology, Children’s Hospital of 

Wisconsin

Paul Nannis, Vice President, Department of 

Government and Community Relations, 

Aurora Health Care; formerly City of 

Milwaukee Health Commissioner

Mary Rotar, RN, Infection Control 

Coordinator for Children’s Health Care 

System and formerly for West Allis 

Memorial Hospital, Milwaukee

Thomas A. Taft, MD, Infectious Disease 

Specialist, Hospital Epidemiologist, 

and Chair of Infection Control at West 

Allis Memorial Hospital; Assistant 

Clinical Professor, St. Joseph’s Hospital, 

Milwaukee

* Case Study Coordinator

Philadelphia 

Carla Campbell, MD, Medical Director, 

Lead Poisoning and Toxicology Clinic, 

Children’s Hospital of Philadelphia; 

Pediatric Consultant, Philadelphia 

Department of Health

*Lisa Donahue, Environmental Scientist, 

EPA Region III, Philadelphia
25

*Karen Johnson, Chief, Safe Drinking Water 

Act Branch, Office of Compliance and 

Enforcement, EPA Region III, Philadelphia

Richard Tobin, Program Director, 

Philadelphia Childhood Lead Poisoning 

Prevention Program

* Case Study Coordinator

Minnesota 

Terri Helland, RN, Public Health Nurse, 

Brown County Public Health

Anita Hoffmann, Director, Brown County 

Public Health

*Bonnie Holz, Public Health Preparedness 

Coordinator, Minnesota Department 

of Health; formerly Environmental 

Health Director for Brown, Nicollet and 

Cottonwood Counties

Kevin Kuehner, Water Quality Specialist, 

Brown Nicollet Cottonwood Water 

Quality Board

* Case Study Coordinator

Physician, Nurse, and Health 

Educator Reviewers 

The following people helped ensure the activity 

met criteria required for a continuing education 

activity within their professions.

Brenda Afzal, RN, BSN, MS, Project Manager, 

University of Maryland School of Nursing, 

Environmental Health Education Center
26

John M. Balbus, MD, MPH

Diane Drew, RN, Senior Health Education 

Specialist, CDC

Cathey E. Falvo, MD, MPH, Professor of 

Public Health Practice, Clinical Associate 

Professor of Pediatrics, New York Medical 

College

Sharon Hall, RN, Public Health Advisor, 

Acting Branch Chief, Learner Support, 

CDC

Barbara Sattler, RN, DrPH, Associate 

Professor and Director, Environmental 

Health Education Center, University of 

Maryland School of Nursing

Lauren Swirsky, MPH, CHES, Senior Health 

Education Specialist, Division of Health 

Education, ATSDR

Dianyi Yu, MD, PhD, Medical Officer, CDC

Special Thanks

In addition to workplaces of the experts 

interviewed, the following organizations have 

contributed video footage, still images, or filming 

locations to this production:

Fairmount Water Works Interpretive Center, 

Philadelphia Water Department

Georgetown Aqueduct in Washington, DC, 

operated by the U.S. Army Corps of 

Engineers
27

School District of Philadelphia

Mulberry Child Care & Preschool, 

Philadelphia

CH Diagnostic & Consulting Services, Inc., 

Loveland, Colorado

U.S. Department of Agriculture, Soil 

Conservation Service

Thank you to all those who participated in pilot 

testing, and to staff at EPA, CDC, and ATSDR, 

too numerous to list, who reviewed multiple drafts 

and provided valuable critiques and advice.

Finally, thank you to all those involved, on- and 

off-camera, in the production of this video. 

The Milwaukee segment was filmed the week 

of September 11, 2001, and the Philadelphia 

and Minnesota segments were filmed just a few 

weeks later. The hospitality and commitment 

of our hosts, and the diligence, support, and 

professionalism of the DC-based crew, made this 

production possible and will not be forgotten.
Office of Ground Water and 

Drinking Water (4606-M)

EPA 816-K-04-001

www.epa.gov/safewater

August 2004