Rural children's exposure to well water contaminants: implications in light of the American Academy of Pediatrics' recent policy statement.

In May, 2009, the American Academy of Pediatrics (AAP) issued a policy statement recommending that pediatric health care providers ask families whether they drink water from a well at home. They also recommend regular biologic and chemical testing of private wells that supply drinking water to U.S. children. The recommendations call for annual testing for nitrates and total coliforms and for less frequent testing for inorganic compounds, gross radioactivity, and lead (Rogan & Brady, 2009a). Policy justification was based on children’s susceptibility to waterborne illnesses, the severity of illness resulting from children’s ingestion of contaminated water, and the lack of regulation addressing private wells. In general, children are more vulnerable to the health effects of waterborne contaminants than adults because they drink more water per kilogram of body weight, have a lifetime of potential exposure, and have immature metabolic pathways (aAAP Committee on Environmental Health, 2003a). For example, infants are particularly susceptible to developing methemoglobinemia from exposure to nitrates, due to their increased capacity to convert nitrate to nitrite and their decreased levels of cytochrome b5 reductase, an enzyme that converts methemoglobin back to hemoglobin (Faustman, Silbernagel, Fenske, Burbacher, & Ponce, 2000; Ward, et al., 2005). Health effects from drinking water contaminants are diverse and depend upon the type of contamination. Bacteria, viruses, and parasites tend to cause gastrointestinal illnesses (bAAP Committee on Environmental Health, 2003b). This is particularly problematic in children who become dehydrated more quickly than adults when they have diarrhea (Rogan & Brady, 2009b). Other contaminants, such as radon, arsenic, chromium, and trichloroethylene, are carcinogenic (bAAP Committee on Environmental Health, 2003b). Nitrates, as mentioned previously, can cause methemoglobinemia in infants (Ward, et al., 2005). Scientists are only beginning to study complex mixtures of drinking water contaminants and their additive or synergistic effects on health (Ryker & Small, 2008). According to the Environmental Protection Agency (EPA), approximately 15% to 20% of households in the U.S. rely on private wells for their drinking water (EPA, 2006, 2008). Private wells are not regulated. Most states make testing of private wells the responsibility of homeowners, although homeowners frequently do not test their well water and if they do they do not necessarily correctly interpret the test results (Jones, et al., 2006; Shaw, Walker, & Benson, 2005). The results of focus groups and a direct-mail survey in Ontario, Canada indicated persons using private well water often believed their water quality was very good (Jones, et al., 2005). Direct mail respondents were concerned about bacterial and chemical contaminants but only 8% frequently tested their water (Jones, et al., 2006). Perceived high quality of well water, knowledge of what to test for and the costs associated with testing are often cited as reasons for not testing private well water (Jones, et al., 2006). The National Water-Quality Assessment Program recently reported that more than one in five domestic wells sampled contained one or more non-microbial contaminants at a concentration greater than a human health benchmark. Microbial contaminants were detected in as many as one-third of a subsample of wells (DeSimone, 2009). Few studies report well water quality in the rural West among low income families. A recent study in Arizona sampled water from the wells of 10 small systems and 39 private individual wells (Marrero-Ortiz, Riley, Karpiscak, & Gerba, 2009). Forty three percent of the wells were positive for total coliforms, 16% for fecal coliforms and 4% for Escherichia coli. Thirty one percent of the wells contained arsenic above the current drinking water standard of 0.010 milligrams per liter. Per the AAP recommendation, common economic activities in the rural West (e.g. extractive mining, smelting, and agriculture), regional radon, and illegal dumping warrant water quality tests for metals, pesticides, radon and volatile organic compounds (See Appendix 1. Flowchart for Testing Well Water) (Rogan & Brady, 2009a). Many of these tests are prohibitively expensive for low income families. The U.S. EPA suggests testing well water annually for total coliform, nitrates, dissolved solids and pH (EPA, 2002). Arsenic occurs naturally in well water in many regions of the U.S. Local health departments are a reliable source of information regarding what contaminants should be evaluated when testing well water. For example, in regions where there is a high level of agriculture, nitrates, pesticides and coliforms should be monitored in well water (EPA, 2009). Limited information is available about well water quality among rural low-income families. Further, little is known about attitudes and protective actions employed by this population to abate risks. To elucidate contextual and logistical issues pertaining to the AAP recommendations, we report cross-sectional findings from an intervention study titled “Environmental Risk Reduction through Nursing Intervention and Education” (ERRNIE). The purpose of this paper is to report sample proportions from well water quality tests conducted for each household, precautionary actions taken by parents, and feasibility and risk communication issues that arose during the course of the study. This information is intended to provide primary care providers with practical advice they can use to help families obtain valid and actionable well test results.