tainted wateron tap

40 AJN t November 2005 t Vol. 105, No. 11 http://www.nursingcenter.com

Stephanie M. Chalupka is a professor of nursing at the University of Massachusetts Lowell anda visiting scientist at the Harvard School of Public Health, Boston. Contact author: Universityof Massachusetts Lowell, School of Health and Environment, Department of Nursing, 3 Solomont Way, Lowell, MA 01854; [email protected]. The author wishes toacknowledge Margaret Dorson, ARNP, GNP, for her assistance with research in the prepara-tion of this manuscript. The author of this article has no significant ties, financial or otherwise,to any company that might have an interest in the publication of this educational activity.

TaintedBy Stephanie Chalupka, EdD, APRN,BC, CNS

OVERVIEW: Annual cases of waterborne illness

in the United States are estimated to number

about 900,000, but most experts believe the inci-

dence to be much higher. The U.S. Environmental

Protection Agency regulates the nation’s drinking

water supply, setting maximum allowable levels for

87 known natural and synthetic contaminants; but

thousands more go unregulated. This article

describes selected contaminants and their known

health effects, which range from acute gastroen-

teritis to cancer and reproductive and developmen-

tal effects. It discusses which populations are more

vulnerable, outlines assessment, and elucidates

nurses’ roles in patient education and as commu-

nity advocates for safer drinking water.

When Hurricane Katrina roiled into NewOrleans on August 29, it contaminated areawater supplies with everything from gasolineto raw sewage. But what many people don’trealize is that it doesn’t take a category five

storm to foul drinking water. In communities across the UnitedStates, local water supplies are threatened or have already beentainted by a range of synthetic and organic contaminants.

One morning in July 2003, I noticed a town highway depart-ment truck spraying herbicide on vegetation along a road nearmy home in Massachusetts. I asked the workers about the prod-uct’s safety and was told that the chemicals were “perfectly safe”and approved for use by both the local board of health and theU.S. Environmental Protection Agency (EPA). But I remainedconcerned; my neighbors and I depend on private wells, whichare susceptible to contamination through runoff and otherroutes, for drinking water.

Further investigation indicated that the local board of healthapparently had not known about roadside spraying of the herbi-cide. I found several epidemiologic studies suggesting that herbicideexposure can have adverse health effects, including genetic muta-tions, cancer, and birth defects. Although most of these studiesinvolved the agricultural use of herbicides, experts were voicingconcern about the potential threat posed by chronic, low-doseexposure through drinking water. And contrary to what the high-

WateronTap

What to tell patients about preventing illness from drinking water.

[email protected] AJN t November 2005 t Vol. 105, No. 11 41

CE4Continuing Education

HOURS

way department workers had told me, the EPA doesnot have an approval process for herbicides and doesnot require testing for hormone or immune systemdamage and other health effects.

Eventually, I learned that in 2002 theMassachusetts Turnpike Authority had adopted azero-use policy for herbicides as a result of scientificdata and concerns that drinking water treatmentprocesses do not adequately filter these chemicals. Ipresented my research to the local board of health.My perseverance paid off: four months later,responding to pressure from the board of health andcommunity residents, the town’s highway depart-ment adopted a zero-use policy in residential areas.

This article describes several types of knowncontaminants of drinking water in this country, dis-cusses assessment when contamination is a sus-pected cause of illness, and describes the nurse’srole in patient education and community advocacy.

Although selected contaminants and their healtheffects are covered, a discussion of treatment isbeyond its scope.

HOW SAFE IS THE WATER?Americans drink a lot of water, “more than 1 billionglasses of tap water per day,” according to the EPA;with the national population estimated to be just shortof 300 million, that’s at least three glasses per persondaily.1, 2 But just how safe is the water we drink?

Americans no longer have much to fear fromwaterborne killers like cholera, dysentery, and typhus,diseases that were rampant 100 years ago. The use ofchlorine to disinfect community water supplies, apractice that began in the early 1900s, has effectivelyeliminated many such diseases in this country.3 Butemerging resistant organisms and increasing environ-mental contamination continue to present significantchallenges. The Safe Drinking Water Act (SDWA) of

A headwater stream in the Allegheny–Monongahela watershed in western Pennsylvania is discolored by acid and heavy met-als leaking from abandoned coal mines. The Allegheny–Monongahela river system ranked fifth on conservation organizationAmerican Rivers’ 2004 “America’s Most Endangered Rivers” list; with the Ohio, its waters serve 42 “public drinking waterintakes” in the region.

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1974 and subsequent amendments charged the EPAwith regulating the nation’s drinking water supply,including setting maximum allowable levels for natu-ral and synthetic contaminants. Yet despite thesemeasures, about 900,000 cases of waterborne ill-ness—and 900 deaths—occur in the United Statesannually, according to an often cited estimate attrib-uted to the Centers for Disease Control andPrevention (CDC).4 Most experts agree that such fig-ures represent only a fraction of the actual occur-rences. Extrapolated data from one interventionstudy suggest that annual cases of waterborne illnessmore likely number about 40 million.5

The EPA regulates only 87 of the thousands ofknown contaminants of drinking water, although thepotential health effects of many, including cancer,developmental effects, and various acute illnesses,are well documented.6 The water systems in manylarge U.S. cities rely on an infrastructure of pipesmore than 100 years old, and old pipes can rupture:in 2002 more than 200,000 water main breaksoccurred nationwide.7 They can also leach chemicalcontaminants such as lead or offer breeding groundfor bacteria. The SDWA does not regulate privatewells or community water suppliers that serve fewerthan 25 people; in some states, as much as half thepopulation drinks from unregulated water systems.8

RECENT OUTBREAKS AND VULNERABLE POPULATIONSSince 1971 the CDC and other agencies have col-lected surveillance data on disease outbreaks in theUnited States associated with drinking water; in1978 they also began gathering data on outbreaks

linked to recreational water use. During the2001–2002 surveillance period, the most recent forwhich data are available, 31 waterborne diseaseoutbreaks associated with drinking water werereported in 19 states.9 An estimated 1,020 peoplebecame ill; 51 were hospitalized and seven died.The cause of illness was identified in 24 outbreaks:19 were associated with pathogens, including sixinvolving Legionella species, and five were linkedto chemical poisoning. Common microbial con-taminants included parasites, bacteria, and viruses.Of the 25 outbreaks not attributed to Legionellaspecies, 23 were linked to contaminated groundwa-ter (water found in underground aquifers that isused for private and municipal wells), includingnine that were associated with unregulated privateor noncommunity wells.

During the same surveillance period, a record 65outbreaks associated with recreational water werereported in 23 states; 2,536 people became ill, 61were hospitalized, and eight died.10 Of the 65 out-breaks, 30 involved gastroenteritis; among these, themost frequently identified contaminants wereCryptosporidium species, found at 50% of thetreated water sites, and Escherichia coli andnorovirus, each found at 25% of the freshwater sites.

Susceptibility to illness from exposure to con-taminated water, as well as the magnitude of thetoxic response, can be influenced by a number offactors, including older or younger age and fragilehealth. The most vulnerable populations—children,older adults, pregnant women, and people who areimmunocompromised—may experience adverseeffects at lower levels of exposure to contaminantsthan other populations.

Many environmental contaminants can havedevastating effects. Prenatal exposure can produceteratogenesis and premature death. Exposure dur-ing infancy and childhood can damage developingorgan systems. Children consume more water perunit of body weight, and they metabolize andexcrete toxins less efficiently than adults do. Olderadults are similarly at risk because diminishedblood flow to the liver and kidneys can decreasetheir ability to eliminate environmental toxins;declining immune function and malnutrition canbe factors as well. For example, a literature reviewby Gerba and colleagues found that nursing homeresidents who contract foodborne bacterial gas-troenteritis are 10 times more likely to die thanthose in the general population who contract thesame illness.11

Gerba and colleagues also found that pregnantwomen are similarly at increased risk.11 Theyreported that two studies found that pregnantwomen are 10 times more likely to die during awaterborne hepatitis E outbreak than those in the

Community Right-to-Know Hotline(800) 424-9346The hotline provides information on the uses andreleases of chemicals by state.

Environmental Protection Agencywww.epa.govRecommended pages:List of Drinking Water Contaminants and MCLs:www.epa.gov/safewater/mcl.htmlLocal Drinking Water Information:www.epa.gov/safewater/dwinfo/index.htmlEPA Map of Radon Zones:www.epa.gov/iaq/radon/zonemap.htmlGround Water and Drinking Water:www.epa.gov/safewater/index.html Recognizing Waterborne Disease and the Health Effects of Water Pollution:www.waterhealthconnection.org

Resources


general population. Altered immune response,hormonal changes associated with pregnancy,and malnutrition have been postulated as possi-ble factors.

MICROBIAL CONTAMINANTSParasites. Common parasitic causes of recentdrinking water–related disease outbreaks includeCryptosporidium species and Giardia intestinalis.9

These organisms can readily infect humans whendrinking water supplies are polluted by sewage oragricultural runoff. Transmission characteristicallyoccurs by the fecal–oral route. Outbreaks are usu-ally associated with contaminated well and surfacewater systems and water treatment failure.

The small size and unique structure ofCryptosporidium species make them resistant tostandard methods of water filtration and disinfec-tion. The organisms have an outer shell that protectsthem outside the human body and also makes themresistant to chlorine treatment. Cryptosporidiosis,the resulting illness, is particularly dangerous forimmunocompromised patients, young children, andthe elderly. In 1993 the largest waterborne-diseaseoutbreak of the late 20th century occurred whenmore than 400,000 people in Milwaukee became illwith diarrhea after drinking Cryptosporidium-contaminated water.12 More than 50 fatalities, mostof them in people with AIDS, resulted.

The incubation period is about one to two days;symptoms, which include dehydration, weight loss,abdominal cramps or pain, fever, nausea, and vom-iting, begin one to 12 days after infection. Somepatients are asymptomatic.

Giardia intestinalis lives in the intestines ofinfected animals and humans and can be found insoil, food, water, or any site contaminated withtheir feces. Symptoms, which usually appearbetween three and 25 days after infection, includediarrhea, steatorrhea, abdominal pain, bloating,nausea, and vomiting. The disease can be transmit-ted as long as the patient remains infected, whichcan be as long as a few months. In cases of chronicgiardiasis, recurring symptoms can be debilitatingand can cause malabsorption.

Bacteria. E. coli O157:H7, a particularly toxicstrain of the bacterium, causes severe bloody diarrheaand abdominal cramps; there is usually little or nofever and some people are asymptomatic. The incu-bation period is typically two to eight days but maybe longer. The illness usually resolves in five to 10days without antibiotic treatment. However, in sus-ceptible populations, particularly children youngerthan five years and older adults, the infection cancause hemolytic uremic syndrome, a life-threateningillness. In the digestive tract, E. coli O157:H7 pro-duces toxins that enter the circulation, attacking ery-throcytes. As the damaged cells accumulate in the

A 30-inch pipe spews out 27,000 gallonsof blackened water per minute at the 17thStreet Canal in New Orleans, Louisiana, onSeptember 9. Contaminated water waspumped into Lake Pontchartrain. Some ofthe effects of Hurricane Katrina and theflooding in New Orleans may not be seenfor years to come. Not the least of the prob-lems is—and will continue to be—contami-nated water. In the weeks after the disaster,EPA testing revealed greatly elevated levelsof E. coli and other coliform bacteria associ-ated with raw sewage, as well as manydangerous chemicals, including lead, con-centrations of which are actually increasedby boiling. The EPA warned both healthcare workers and the public to avoid con-tact with the polluted water and to avoiddrinking it, if at all possible. According tothe EPA, likely symptoms of ingestion arestomachache, fever, vomiting, and diarrhea.Infection at wound sites is also likely amongthose coming into contact with the filthywater; people with fever along with rednessand swelling at wound sites are admon-ished to seek medical treatment. For links toinformation on the contaminants found inthe floodwaters, go to http://sis.nlm.nih.gov/enviro/hurricane.html. AP Photo/Steven Senne


kidneys, waste filtration is impaired. The resultingbuildup of excess fluid can cause hypertension andswelling of the hands and feet; in some cases, the ill-ness can progress to acute kidney failure.

Campylobacter jejuni causes campylobacteriosis;the illness has an incubation period of between twoand five days after exposure and can last as long asa week. Symptoms include diarrhea, abdominalcramping or pain, malaise, nausea, and vomiting.Long-term complications can include reactivearthritis or Guillain–Barré syndrome (it’s believedthat as many as 40% of cases of Guillain–Barré aretriggered by campylobacteriosis13).

Salmonella enterica typhimurium infection usu-ally resolves in five to seven days; treatment isn’trequired unless the patient becomes severely dehy-drated or the infection spreads from the intestines.Symptoms include diarrhea, fever, abdominalcramps, nausea, and vomiting. Infection may alsopresent as septicemia, an abscess, reactive arthritis,or cholecystitis.

Enteric viruses include noroviruses, rotaviruses,adenoviruses, astroviruses, and hepatitis A.9 Virusesare much more resistant to chlorine disinfectionthan bacteria are. Symptoms of infection includewatery diarrhea, vomiting, headache, fever, andabdominal cramps; such symptoms usually appearone to two days after infection and can last as longas 10 days. It can be especially difficult to identifyenteric viral infections; nurses are more likely to beaware of parasitic and bacterial causes of thesesymptoms and may not consider viral causes. It’slikely that many outbreaks of “stomach flu” withresulting vomiting or diarrhea are actually causedby enteric viruses.14

CHEMICAL CONTAMINANTSMore than 70,000 chemicals are produced annu-ally in the United States.15 Hundreds of these chem-icals may be found in drinking water suppliesnationally, although many have never been testedregarding their toxicity for humans or the environ-

TABLE 1. Keeping it Clean

WaterTreatmentMethod*

How It Works Some Contaminants Treated

Adsorption Particles in the water adhere to the surface or pores of adsorbentmediums, such as carbon or charcoal. A filter contains the carbonor charcoal; when water is passed through it, the contaminants areremoved.

Volatile organic chemicals (VOCs), pesticides, trihalomethanes

Water softeners

Water softeners use a cation-exchange resin, regenerated withsodium chloride or potassium chloride, to reduce the “hardness” ofthe water. Calcium and magnesium ions are replaced with sodiumor potassium ions.

Calcium and magnesium

Ultraviolet(UV) light

Water is passed through a tube that is exposed to UV light, which isa microbicide.

Bacteria and viruses (some systems treatonly heterotrophic bacteria)

Reverseosmosis

Water molecules are forced through a membrane that blocks largerinorganic particles from passing through.

Pesticides, dioxins, and VOCs

Distillation Water is heated to the boiling point in one chamber; the steam iscollected in a separate chamber. When the water is completelyvaporized, many contaminants, including nitrates, bacteria, heavymetals, and radionuclides, are left behind. The cooling steam con-denses into purified water. Household distillers are generally usedfor drinking or cooking water.

Arsenic, barium, cadmium, chromium,and lead

*For a complete list of water treatment technologies and products that reduce specific contaminants and are certified by theNational Sanitation Foundation, see www.nsf.org/consumer/drinking_water/dw_treatment.asp?program=WaterTre.National Sanitation Foundation International. Home water treatment devices: drinking water treatment technologies. 2004. http://www.nsf.org/consumer/drinking_water/dw_treatment.asp?program=WaterTre#technologies.


(THMs), haloacetic acids, bromate, and chlorite.Some studies have demonstrated associationsbetween exposure to disinfectant byproducts indrinking water and various adverse health effects.For example, epidemiologic and toxicologic studieshave shown a link between such exposure andbladder and rectal cancers.20, 21 Studies have alsofound associations between chlorinated drinkingwater and reproductive and developmental out-comes such as stillbirth, congenital cardiac defects,intrauterine growth retardation, and low birthweight.22, 23 Pregnant women exposed to water withincreased levels of THMs appear to be at higherrisk for pregnancy-related complications, includingbirth defects, stillbirth, spontaneous abortion, andfetal growth retardation.22, 24 However, other studieshave found no such associations between exposureto disinfectant byproducts and adverse healtheffects, and the debate is ongoing.

The EPA has stated that it considers disinfectantbyproducts “a potential hazard concern” and hassupported regulatory action.25 In 1998 the EPA’sStage 1 Disinfectants and Disinfection ByproductsRule set goals for maximum allowable levels of dis-infectants and disinfectant byproducts in water sys-tems. Large surface water systems were required tocomply by 2002; groundwater systems, by 2004.However, with the exception of the District ofColumbia and Wyoming, all other states have “pri-macy,” which means that the states, not the EPA,have primary enforcement authority. Compliancedata can be accessed only through state databases;no federal database exists. A proposed Stage 2Disinfectants and Disinfection Byproducts Rule,aimed at further reducing exposure levels andhealth risks, is slated for review in December.26

Lead. Lead-contaminated drinking water mayaccount for as much as 20% of a person’s totalexposure to lead, and that percentage may behigher in infants drinking formula prepared withlead-contaminated water, according to the EPA.27

Even though in 1986 Congress banned the use oflead solder with more than 0.2% lead and limited the

ment.16 According to the Institute of Medicine,recent data released by the United States GeologicalSurvey show that “new contaminants and contam-inant mixtures”—such as natural and synthetichormones and pharmaceuticals—are “appearing inour surface waters.”17 Surface water is water foundon the surface of the earth, such as in lakes, rivers,or streams—about half of all Americans get theirdrinking water from a surface water supply; halfobtain it from groundwater.18

Water becomes polluted through “point sources,”easily identified sources that discharge chemicals intothe environment, such as factories, or through “non-point sources,” less easily discernible sources carry-ing agricultural or industrial runoff, such as meltingsnow or paved roads. Chemicals can enter surfacewater reservoirs directly or seep into undergroundaquifers to contaminate groundwater. Inorganicchemicals (such as arsenic, beryllium, cyanide [as freecyanide], and nitrites), synthetic organic chemicals(such as vinyl chloride, toluene, benzene, anddioxin), pesticides, and herbicides are found in lowconcentrations in many drinking water systems.Many pesticides that were once widely used, such asdichlorodiphenyltrichloroethane (DDT) and otherchlorinated hydrocarbons, have been banned fordecades but are resistant to degradation; such chem-icals are known as persistent organic pollutants.

There is concern about the risks of drinkingwater that contains even very low levels of knownor suspected carcinogens or of chemicals with docu-mented adverse neurologic, reproductive, or terato-genic effects. For example, halogenatedhydrocarbons (such as trichloroethylene, a solventand an ingredient in adhesives and in paint and spotremovers) are among the most common water sup-ply contaminants in this country. Low-level expo-sure to trichloroethylene has been associated withimmune system impairment, kidney and liver dam-age, and impaired fetal development.19 Selectedchemical contaminants found in drinking water andsome of their potential health effects are discussed below; for a more complete listing of all types of drinking water contaminants, go towww.epa.gov/safewater/mcl.html#mcls. It’s alsoimportant for patients to realize that exposure tochemical contaminants isn’t confined to ingestion;volatile chemicals, such as benzene, are easilyabsorbed through the skin or inhaled from heatedor aerosolized water, which means that bathing isanother potential source of exposure.

Disinfectant byproducts. Water treatment withdisinfectants such as chlorine, ozone, chloramines,and chlorine dioxide reduces the levels of microbialcontaminants. But these disinfectants can reactwith organic matter such as decaying vegetation tocreate byproducts, including trihalomethanes

Two studies found that pregnantwomen are 10 times more likelyto die during a waterborne hepatitis E outbreak than those in the general population.


In their pursuit of safer drinking water, many peo-ple consider adding household filtration or treat-

ment devices or drinking bottled water. Nurses canhelp patients to make informed decisions by know-ing which contaminants may be affecting localdrinking water and by understanding the potentialbenefits and risks of alternative sources. If thehousehold is served by a public water utility, basicdrinking water information is available through aconsumer confidence report (see The ConsumerConfidence Report, page 49).

Household water treatment and filtration sys-tems have become increasingly popular in recentyears. According to Consumer Reports,Americans spend more than $1 billion on house-hold water filtration annually.1 Various treatmenttechnologies are available. Point-of-use systemstreat water at a single tap and may be installed atthe faucet, on a counter, or under a sink. Point-of-entry sys-tems are installed where the water line enters the houseand treat water used throughout the house.

Filters differ in their capacity to reduce chemical andmicrobiologic contaminant levels, such as disinfectantbyproducts, lead, and parasites. Not all filters can removeall types of contaminants. Moreover, any filtration systemmust be maintained or it will eventually become ineffectiveand, if accumulated contaminants are released back into thedrinking water, a health hazard. Although the U.S.Environmental Protection Agency (EPA) does not test or cer-tify water filtration devices, it recommends that such devicesmeet the standards of the Water Quality Association(www.wqa.org) or the National Sanitation FoundationInternational (www.nsf.org).2

Bottled water. Americans drink an estimated 6 billiongallons of bottled water annually.3 But bottled water is notnecessarily safer than tap water; indeed, an estimated25% or more of bottled water sold in the United Statesmay be tap water.4 Moreover, a four-year study by theNatural Resources Defense Council found syntheticorganic chemicals, bacteria, and arsenic in water sam-ples representing 103 brands of bottled water.4 One-thirdof the samples violated established industry or state limitson contaminant levels.

There are important differences between regulations gov-erning tap water and bottled water. The EPA sets standardsfor tap water, but nationally sold bottled water falls under thejurisdiction of the U.S. Food and Drug Administration(FDA)—and water bottled and sold within the same state isexempt from both EPA and FDA regulations. Moreover, manystates lack state regulations regarding water bottled and soldwithin the state, and these unregulated bottles account for60% to 70% of bottled water.4 The FDA also exempts car-bonated water and seltzer from the oversight process.

Each time the EPA establishes a standard for a chemi-cal or a microbial contaminant, the FDA is free to adopt it

or not.5 For example, EPA rules prohibit tap water fromcontaining any coliform bacteria, including E. coli, but theFDA stipulates a maximum allowable limit for coliform bac-teria. Municipal water systems must test tap water for col-iform bacteria at least 100 times per month, while FDAregulations for bottled water plants require weekly coliformbacteria testing. The less rigorous requirements for somemicrobial contaminants are of greater concern for popula-tions at higher risk of infection, such as people with a com-promised immune system, older adults, and infants. Onlybottled water that’s labeled “filtered through an absolute 1-micron or smaller filter,” “one micron absolute,” “dis-tilled,” or “reverse-osmosis treated” has been processed bymethods effective against Cryptosporidium species.6

Some parents may buy more costly bottled water mar-keted and labeled as being “for use in preparing infant for-mula.” They should be cautioned that such products areonly required to meet EPA standards for tap water.7

REFERENCES1. Clear choices for clean drinking water. Consum Rep 2003;68(1):

33-8. 2. U.S. Environmental Protection Agency. Draft report on the

environment. 2003. http://www.epa.gov/indicators/roe/html/roeTOC.htm.

3. Doss JK. A world of opportunities. President’s remarks.Worldwide Food Expo; 2003 Oct 30; Chicago: InternationalBottled Water Association; 2003.http://www.bottledwater.org/public/2003_Releases/Presidents_remarks_10_30_2003.html.

4. Natural Resources Defense Council. Bottled water: pure drink or pure hype? 1999. http://www.nrdc.org/water/drinking/bw/bwinx.asp.

5. U.S. Department of Health and Human Services. Beverages: bot-tled water; final rule. Federal Register 2003;68(41):9873-82.

6. Centers for Disease Control and Prevention. Preventing cryp-tosporidiosis: a guide to water filters and bottled water. 2004.http://www.cdc.gov/ncidod/dpd/parasites/cryptosporidiosis/fact-sht_crypto_prevent_water.htm.

7. U.S. Food and Drug Administration. I have seen bottled watermarked for use in preparing infant formula. What does this mean?1997. http://www.cfsan.fda.gov/~dms/qa-inf3.html.

Drinking Water Choices: Filters, Bottles, and Beyond

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lead content of faucets, pipes, and other plumbingmaterials to eight, older homes may still have lead-based plumbing.28 In many large cities, lead piping stillconnects municipal water mains to homes. Drinkingwater—especially water that is acidic (has below-neu-tral pH) or soft (has low mineral content)—can causelead to leach from lead-soldered joints and lead con-nector pipes, as well as from brass fixtures.

Lead has long been recognized as neurotoxic; inchildren the effects of exposure can be devastating.Clinical manifestations vary somewhat, dependingon blood lead levels, which are determined, in part,by duration and intensity of exposure. Some effectsof exposure may be latent. Overt clinical symptomsand health effects produced by high exposure levelscan differ from person to person; however, a lack ofsymptoms doesn’t mean that lead poisoning has notoccurred. Lower levels of exposure may causenumerous subtle health effects, including decre-ments in IQ scores and changes in peripheral nervefunction. In infants and young children, continuousexposure to high environmental levels can result indelayed physical and cognitive development andlearning disabilities. Lead exposure in adults canresult in kidney problems or hypertension.27

Assessment of blood lead levels is best accom-plished by the collection of a venous blood sample.The CDC, stating that “there is no apparent thresh-old at which the adverse effects of lead do notoccur,”29 defines a blood lead level of 10 microgramsper deciliter or greater in children as elevated.Children with blood lead levels greater than 60micrograms per deciliter can experience abdominalpain, a loss of appetite, constipation, headaches, agi-tation, clumsiness, decreased activity, or somnolence.

Nurses should ensure that lead screening testsare performed in infants and that children areassessed for symptoms of lead toxicity. If elevatedblood lead levels are found, lead in the family’sdrinking water must be considered as a possiblecause. Testing for lead in drinking water in homes,day care centers, and schools should be conductedby state-certified laboratories.

To prevent exposure to lead through drinkingwater, counsel families to use only cold water fordrinking, cooking, and the preparation of infant for-mula because hot water can cause leaching. Foodsthat require or absorb water during preparation(such as soup, rice, and pasta) will absorb lead andother contaminants present in the water as well.27 Ifcold water hasn’t been accessed in several hours,instruct the family to let the tap run for at least 30seconds or longer, in order to flush standing waterfrom the system that may contain leached lead.27

Nitrates. The most common inorganic nitratesfound in drinking water are potassium nitrate andammonium nitrate, both widely used as fertilizers.

Sources of organic nitrate contamination includelivestock manure (especially from large-scale oper-ations such as feedlots), leakage from substandardprivate septic systems, and discharge from munici-pal wastewater treatment plants.30

Nitrates convert to nitrites inside the body; thisprocess interferes with the oxygen-carrying capacityof the blood. Even short-term exposure in infantsyounger than six months can lead to methemoglo-binemia, an acute condition in which health deterio-rates rapidly; if untreated, anoxia may be followed bybrain damage and death. It’s most common in infantswho are already sick, eat foods high in nitrates (suchas broccoli), and drink formula prepared with nitrate-contaminated water.27 Symptoms include shortness ofbreath, bluish mucous membranes and skin tone, andat high levels of exposure, altered mental status anddelirium. Symptoms of excessive nitrate levels in olderchildren include irritability, tachypnea, altered mentalstatus, and headache.

NATURAL GROUND DEPOSITS The erosion of natural ground deposits may causethe release of radionuclides, isotopes that emit someform of radiation, such as alpha and beta particles,ultraviolet light, and X-rays. Radionuclides are theresult of naturally occurring decay of radioactiveelements such as uranium and radium. Althoughthere are hundreds of different radionuclides, only afew are common enough to be of concern. Exposureis associated with an increased risk of cancer.

Radon is a colorless, odorless gas produced bythe natural decay of uranium. Its radionuclides (themost common is radon-222) emit alpha particleradiation. A carcinogen, radon causes approxi-mately 20,000 lung cancer deaths annually.31

Radon is found in soil, rock, air, and waternationwide, although some geographic areas havehigher levels than others. Data from public watersuppliers indicate that elevated concentrations ofradon in water occur primarily in the New Englandstates, the Appalachian states, the Rocky Mountainstates, and small areas of the Southwest and GreatPlains.32 Radon quickly leaves water that is agitatedor exposed to air. Thus concentrations are low inmunicipal water supplies that use surface water

If elevated blood lead levelsare found, lead in the family’sdrinking water must be considered as a possible cause.


reservoirs; the highest concentrations are found ingroundwater and private water supplies such ashousehold wells. Maximum allowable contaminantlevels for many radionuclides have been establishedin the National Primary Drinking Water Regula-tions; however, there is still no standard with regardto radon in drinking water.6

In the home setting, people are exposed to radonin several ways. Radon is distributed primarilythrough air. When water is agitated, as duringshowering and dishwashing, radon is released intothe household air, boosting airborne radon levelsand resulting in increased inhalation exposure.Radon in drinking water is believed responsible forabout 180 deaths annually, causing stomach cancerwhen it’s ingested in drinking water and lung can-cer when it’s released to air from drinking water.32

Radon can also be present in natural gas supplies.There are no signs and symptoms of radon expo-

sure. The most common health effect caused byradon exposure in residential settings is lung cancer,and it’s well documented that smokers are at espe-cially high risk. For example, according to theAgency for Toxic Substances and Disease Registry,a smoker exposed to radon is 10 times more likelyto develop lung cancer than is a lifelong nonsmokerexposed to radon.33 And a recent analysis of datafrom 13 case–control studies yielded more disturb-ing results: the researchers determined that amongpeople exposed to radon, the risk of lung cancer insmokers was 25 times greater than in people whohave never smoked.34

Nurses can encourage patients in areas known tohave high radon levels to test their homes and waterfor radon. Explain that activities such as dishwash-ing, showering, doing laundry, and even flushing thetoilet can release radon into indoor air and result inincreased exposure through inhalation. Water filtra-tion systems that use granulated activated charcoalcan trap radon and reduce levels in drinking water.However, individual tap filters should not be used,because radon released through agitation can stillenter the air and actually increase inhalation expo-sure. Instead, filtration systems should be installedat the site where water enters the house.

Arsenic, a naturally occurring element that isfound in rock and soil worldwide, enters surface andgroundwaters primarily through erosion. Inorganicarsenic compounds are used as wood preservativesand in the manufacture of insecticides, herbicides,glass, metals, and electronics; industrial dischargeand runoff from landfills therefore contribute toarsenic contamination of soil, air, and water.

Because clinical manifestations of arsenic expo-sure differ among individuals, population groups,and geographic regions, there is no standard defini-tion for arsenic poisoning. In children, there is some

evidence that polymorphisms in the CYT19 genemay affect arsenic metabolism and thus influence themanifestations of arsenic exposure.35 Early symp-toms of acute toxicity include vomiting, abdominalpain, and bloody “rice water” diarrhea.

Chronic arsenic poisoning after long-term expo-sure to contaminated drinking water manifestsquite differently. Adverse effects include skin, lung,bladder, and kidney cancer, as well as conditionssuch as altered pigmentation and hyperkeratosis.Cancer generally appears after more than 10 yearsof chronic exposure.36

Urine testing is the most reliable way to assesswhether arsenic exposure has occurred within thepast few days. Hair and fingernail testing are usefulfor measuring high-level exposure that occurred sixto 12 months earlier. Arsenic can be removed fromwell water at the household point of entry, usingadsorption, reverse osmosis, or distillation.37

PRIVATE WATER SUPPLIES AND FILTRATIONAbout 15% of Americans obtain their drinkingwater from private water supplies, in most casesfrom groundwater drawn through wells.38 There areno federal regulations for routine contaminant test-ing of privately supplied drinking water, and theEPA doesn’t have the authority to regulate thesewells. Almost all states license or register wellinstallers, who must comply with basic constructionstandards, but after construction is completed, it’susually the homeowner’s responsibility to maintainthe well and ensure the safety of the water supply.

Suburban “sprawl” is bringing more businessesand industries into rural areas that rely on house-hold wells; new housing developments are beingbuilt at the edges of rural and agricultural areas notserved by municipal sewer and water supply lines.Many of these new homes rely on household wellsand septic systems. Some homeowners may nothave experience with maintaining these systemsand may believe that well water is always pure;unfortunately, groundwater contamination is pres-ent in all 50 states.38

WHAT YOU CAN DO Through patient education and community advo-cacy, nurses can help reduce the risk of waterborneillness in vulnerable populations and improve thestatus of the local drinking water supply. Becomingmore knowledgeable is the first step.

Counsel patients and families about protectingtheir household water supply. Provide them withinformation about potential sources of contamina-tion and ways to prevent this, as well as ways to min-imize the risk of infection. Handwashing remainsone of the most effective measures one can take toprevent microbial infections; remind patients and


family members to wash their hands before, during,and after food preparation, as well as after using thetoilet or changing a baby’s diaper.

Families should also be counseled on how tosafeguard their groundwater. Protective measuresinclude39

• pumping and inspection of septic systems atintervals recommended by the local healthdepartment.

• never disposing of hazardous materials in septicsystems.

• not mixing or using pesticides, fertilizers, herbi-cides, degreasers, fuels, and other pollutants nearwells.

• never disposing of wastes in dry or abandonedwells.Explain to patients and families the value of hav-

ing the household drinking water tested. It’s a com-mon misconception that contaminants in water canbe detected through changes in its taste, appear-ance, or odor; many contaminants, including bac-teria, heavy metals, radon, and synthetic organicchemicals, are detectable only through laboratorytesting.

Provide information about water testing protocolsand interpretation of the test results. Wells should betested annually for pH levels, coliform bacteria suchas E. coli, nitrates, total dissolved solids, and any con-taminants of concern locally.38 For example, in areasof high radon activity (particularly, bedrock wells),radon testing of the water is indicated; in agriculturalregions, testing water for herbicide and pesticide con-tamination is indicated. Testing should be performedmore frequently if chemical or fuel spills are knownto have occurred—regardless of when a spill hap-pened—and whenever there is a change in watertaste, odor, or clarity. Water testing should always beperformed by the local health department or a state-certified laboratory, not by commercial vendors ofwater filtration systems.

Consider the possibility of waterborne illnesswhen encountering acute gastroenteritis ofunknown etiology. You can improve surveillanceefforts for waterborne illnesses by assuming ahigher index of suspicion in such cases. It’s essentialto obtain a drinking water history. Ask patientsabout sources of drinking water at home, school,and work; recreational water exposures (swimmingand hot tub); and travel abroad. General questionsabout drinking water might include the following:• What are your sources of drinking water at home

(for example, municipal water from the tap,municipal water processed with a home filter,private well water, bottled water)?

• If you use a filtering system, has the filter beenchanged according to the manufacturer’s direc-tions?

In 1996 an amendment to the Safe Drinking Water Actrequired that all community water systems produce a “con-

sumer confidence report” (CCR) annually, beginning in 1999,with the aim of giving consumers a “snapshot of their drinkingwater supply.”1 The Environmental Protection Agency (EPA) hasestimated that this rule affects 55,000 water systems and servesto inform about 248 million Americans.1 Larger water systemsmail the CCR to paying customers and post it on the Internet;smaller systems (those serving fewer than 10,000 people) maydisseminate information through newspapers. Nurses can helppatients understand their CCR and use the information pre-sented when making decisions about their drinking water.

States have the option of setting some alternative reportrequirements. However, all CCRs must adhere to certain base-line standards, including those listed above, to ensure that allconsumers receive comparable reports containing the sametype and amount of essential information1:

• the source of the drinking water• a summary of the source’s susceptibility to contamination • levels of contaminants found in the drinking water and

their likely health effects, as well as maximum allow-able contaminant levels set by the EPA

• the likely source of identified contaminants• an accounting of the system’s actions to address the

contamination• educational information about selected contaminantsSome water systems, such as community systems serving

fewer than 25 people, are exempt from having to publish aCCR.

The most significant limitation to a CCR’s usefulness is thatsystems need only report levels of regulated contaminants—unregulated contaminants, such as pesticides and herbicides,need not be reported. Other limitations include the fact that aCCR provides data from the previous calendar year, rather thancurrent data. And the language of the report can be technicalor otherwise difficult for some to understand without assistance.

REFERENCE1. U.S. Environmental Protection Agency. Consumer confidence reports:

final rule. Washington: The Agency; 1998. EPA 816-F-98-007.http://www.epa.gov/safewater/ccr/ccrfact.html.

The Consumer Confidence Report

If the patient has a well, ask:• When was the last time your well water was

tested for contaminants?• What contaminants was it tested for?• Do you use a state-certified laboratory for water

testing?• Do you use pesticides, fertilizers, or other chem-

icals on your lawn?If there are children in the home, these questionsmight be helpful:• Does your home have lead pipes?• Have your children been tested for lead exposure?


Thinking Globally, One Water Jug at a Time

(allowing coagulation and precipitation of heavy met-als, pesticides, and other chemical contaminants).

• filters the water through a clean cloth.• lets the filtered water stand for 20 minutes (allowing

disinfection). In one recent study, researchers found that the purifier

reduced 14 types of waterborne bacterial pathogens(including Salmonella typhi, Vibrio cholerae, and Escherichiacoli) to undetectable levels and removed 99.8% of arsenic.4

It also significantly reduced the levels of poliovirus, rotavirus,and Cryptosporidium. Its effectiveness was tested in U.S.Environmental Protection Agency “model” water samplesand in field samples from Guatemala, Kenya, Pakistan, thePhilippines, and South Africa. Similar results were seen inBangladesh, where arsenic-contaminated water is common.

Tests were conductedunder both laboratoryand “real-life” condi-tions, in which sampleswere stirred andallowed to stand afterfiltering for shorter-than-recommended times.Other studies have con-

When one Googles the phrase “dirty water,”the first hits include Web pages for the

Boston Rock & Roll Museum (www.dirtywater.com)and the Dirty Water Club, a hip London hangout,apt tributes to the Standells’ 1966 hit single “(I LoveThat) Dirty Water.” Its chorus was a paean toBoston’s Charles River: “Oh, I love that dirty water,oh Boston, you’re my home.” But to billions of peo-ple worldwide—the 2.6 billion who live withoutadequate sanitation and the 1.1 billion who lackaccess to safe drinking water1—dirty water meanstragedy. According to the World HealthOrganization, diarrheal diseases kill 1.8 millionpeople annually, most of them children in develop-ing nations; 88% of these cases are attributed tocontaminated drinking water, inadequate sanitation,and poor hygiene. And, as the Washington Postreported in March 2003, an analysis issued by theUnited Nations that year revealed that the planet’swater supply is dwindling fast: by the year 2023,“the average supply of water per person worldwidewill have dropped by one-third.”2

Together with the International Council of Nurses (ICN) andthe Centers for Disease Control and Prevention, the P&GHealth Sciences Institute, a Procter & Gamble division based inCincinnati, Ohio, has developed and tested a point-of-usewater purifier (PuR Water Purifier). The product contains “thesame ingredients used in municipal water systems”3—includinga coagulant, an alkaline agent, a flocculent, and a chlorine-based disinfectant—packaged in single-use sachets.4 The onlyequipment needed: two containers capable of holding 10liters (2.5 gallons) of water each, and something to stir with.

Decontamination is a three-step process. The user3

• adds the contents of one sachet to a 10-liter (2.5-gallon) container of water and stirs for five minutes

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• What kind of water do you use to prepare infantformula?Patients identified as being at risk for drinking

water–related illness should be provided withappropriate counseling. Offer patients informationabout water treatment systems and bottled water.All possible cases of waterborne illness should be

reported to the hospital infection control depart-ment or directly to the local health department, asappropriate.

Take steps to safeguard the community watersupply by becoming more knowledgeable about itsdrinking water, as well as existing and potentialsources of contamination. By law all community

The PuR Water Purifier only requires two containers and something to stir with to complete decontamination.

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Children at the orphan center in Moyo, Uganda, sing for the visiting nurseswho provide PuR demonstrations and ongoing education about the impor-tance of safe drinking water and good hygiene and sanitation practices.


Act as resource for patients, colleagues, and mem-bers of the community.

Other measures nurses can take include promot-ing policies and legislation that enforce andstrengthen current drinking water regulations andsupport the modernization of old and deterioratingpublic water systems. Bottled water and water fil-tration devices can at best offer only short-termrelief from the ills associated with contaminatedwater; the long-term solution lies in improvingmunicipal and private water supplies. t

REFERENCES1. U.S. Environmental Protection Agency. Protect your drink-

ing water for life. 2005. http://www.epa.gov/safewater/pub-licoutreach/index.html.

2. U.S. Census Bureau. U.S. POPClock projection. 2005.http://www.census.gov/population/www/popclockus.html.

3. Centers for Disease Control and Prevention. Achievementsin public health 1900–1999: control of infectious diseases.MMWR Morb Mortal Wkly Rep 1999;48(29):621-9.

4. Rose JB, et al. Microbial pollutants in our nation’s water:environmental and public health issues. Washington, DC:American Society for Microbiology; 1999.

5. Physicians for Social Responsibility. Drinking water and dis-ease: what health care providers should know. 2000. http://www.envirohealthaction.org/upload_files/dwprimer.pdf.

6. U.S. Environmental Protection Agency. List of contaminantsand their MCLs. Washington, DC: The Agency; 2002. EPA816-F-02-013. http://www.epa.gov/safewater/mcl.html#mcls.

7. Natural Resources Defense Council. What’s on tap?Grading drinking water in U.S. cities. 2003. http://www.nrdc.org/water/drinking/uscities/contents.asp.

8. Barron G, et al. New approaches to safe drinking water. J Law Med Ethics 2002;30(3 Suppl):105-8.

9. Blackburn BG, et al. Surveillance for waterborne-diseaseoutbreaks associated with drinking water: United States,2001–2002. MMWR Surveill Summ 2004;53(8):23-45.

10. Yoder JS, et al. Surveillance for waterborne-disease out-breaks associated with recreational water: United States,2001–2002. MMWR Surveill Summ 2004;53(8):1-22.

11. Gerba CP, et al. Sensitive populations: who is at the greatestrisk? Int J Food Microbiol 1996;30(1-2):113-23.

12. U.S. Environmental Protection Agency. Draft report on theenvironment. 2003. http://www.epa.gov/indicators/roe/html/roeTOC.htm.

13. Dingle KE, et al. Sequence typing confirms that Campylo-bacter jejuni strains associated with Guillain-Barré andMiller-Fisher syndromes are of diverse genetic lineage,serotype, and flagella type. J Clin Microbiol 2001;39(9):3346-9.

14. Centers for Disease Control and Prevention. Viral gastroen-teritis. 2005. http://www.cdc.gov/ncidod/dvrd/revb/gastro/faq.htm.

15. U.S. Environmental Protection Agency. Chemical testingoverview. 2004. http://www.epa.gov/oppt/chemtest/view.htm.

16. U.S. Environmental Protection Agency. Chemical hazarddata availability study. 2004. http://www.epa.gov/opptintr/chemtest/hazchem.htm.

17. Institute of Medicine. From source water to drinking water:workshop summary. Washington, DC: National AcademiesPress; 2004: 8.

18. U.S. Environmental Protection Agency. Factoids: drinkingwater and ground water statistics for 2004. Washington,DC: The Agency; 2005. EPA 816-K-05-001. http://www.epa.gov/safewater/data/pdfs/data_factoids_2004.pdf.

firmed the water purifier’s effectiveness in removingarsenic and microbial contaminants.5-7

Earlier this year, the United Nations Children’s Fundand P&G announced a joint campaign aimed at “pro-viding home-based water purification” to families indeveloping countries; the company will supply PuR atcost (about 4 cents per packet).8 Working with localnursing and health care organizations, the ICN contin-ues to train nurses and other providers in the product’suse and to coordinate outreach and distribution efforts.In Uganda the ICN and P&G, working in partnershipwith the Ugandan Association of Nurses and Midwives,are currently providing two centers for childrenorphaned by AIDS with PuR, as well as education in itsuse and the importance of improving drinking watersafety and sanitation and hygiene practices. Within a10-month period, diarrheal rates at the orphan centershave declined from between 12.5% and 14% weeklyto almost zero. A similar project is scheduled to beginin Malawi later this year.—Sylvia Foley, senior editor

REFERENCES1. World Health Organization. Water, sanitation and hygiene

links to health. 2004. http://www.who.int/water_sanita-tion_health/publications/facts2004/en/index.html.

2. Weiss R. Threats posed by water scarcity detailed: U.N. reportwarns of looming crisis. Washington Post 2003 Mar 5; 3.

3. Procter and Gamble. Children’s Safe Drinking Water [factsheet]. Cincinnati, OH; 2005.

4. Souter PF, et al. Evaluation of a new water treatment forpoint-of-use household applications to remove microorgan-isms and arsenic from drinking water. J Water Health2003;1(2):73-84.

5. Norton DM, et al. Flocculent-disinfectant point-of-use watertreatment for reducing arsenic exposure in Bangladesh.[abstract]. Asian Conference on Diarrhoeal Diseases andNutrition; 2003 December 7–9; Dhaka, Bangladesh:International Centre for Diarrhoeal Disease Research,Bangladesh; 2003.

6. Rangel JM, et al. Epidemiology of Escherichia coli O157:H7outbreaks, United States, 1982–2002. Emerg Infect Dis2005;11(4):603-9.

7. Crump JA, et al. Household based treatment of drinkingwater with flocculant-disinfectant for preventing diarrhoeain areas with turbid source water in rural western Kenya:cluster randomised controlled trial. BMJ 2005;[Epub aheadof print Jul 26]. http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38512.618681.E0v1.

8. United Nations Children’s Fund. UNICEF and Procter andGamble join forces on safe drinking water for children.2005. http://www.unicef.org/media/media_27124.html.

water systems must produce an annual “consumerconfidence report” on the status of the local drink-ing water supply; nurses need to become familiarwith this document. (See The Consumer ConfidenceReport, page 49.) Ask your local water utilitywhether there has been a review of potential pollu-tion sources; if not, urge the utility to perform one.


19. Agency for Toxic Substances and Disease Registry.ToxFAQs for trichloroethylene (TCE). The Agency. 2003.http://www.atsdr.cdc.gov/tfacts19.html.

20. Villanueva CM, et al. Disinfection byproducts and bladdercancer: a pooled analysis. Epidemiology 2004;15(3):357-67.

21. Hildesheim ME, et al. Drinking water source and chlorina-tion byproducts. II. Risk of colon and rectal cancers.Epidemiology 1998;9(1):29-35.

22. Wright JM, et al. Effect of trihalomethane exposure on fetaldevelopment. Occup Environ Med 2003;60(3):173-80.

23. Cedergren MI, et al. Chlorination byproducts and nitrate indrinking water and risk for congenital cardiac defects.Environ Res 2002;89(2):124-30.

24. Nieuwenhuijsen MJ, et al. Chlorination disinfection byprod-ucts in water and their association with adverse reproduc-tive outcomes: a review. Occup Environ Med 2000;57(2):73-85.

25. U.S. Environmental Protection Agency. Drinking water con-taminants. 2002. http://www.epa.gov/enviro/html/sdwis/water_contaminants.html.

26. U.S. Environmental Protection Agency. Proposed stage 2disinfectants and disinfection byproducts rule. Washington,DC: The Agency; 2003. EPA 815-F-03-006. http://www.epa.gov/OGWDW/stage2/pdfs/fact_%20st2_proposed.pdf.

27. U.S. Environmental Protection Agency. Tap into prevention:drinking water information for health care providers.Washington, DC: The Agency; 2004. EPA 816-K-04-001.http://www.epa.gov/safewater/healthcare/pdfs/booklet_healthcarevideo_suppliement.pdf.

28. U.S. Environmental Protection Agency. Is there lead in mydrinking water? Washington, DC: The Agency; 1993. EPA810-F-93-001. http://www.epa.gov/safewater/lead/leadfact-sheet.html.

29. Centers for Disease Control and Prevention. Introduction.In: Managing elevated blood lead levels among young chil-dren: recommendations from the Advisory Committee onChildhood Lead Poisoning Prevention. Atlanta: The Center;2002. http://www.cdc.gov/nceh/lead/CaseManagement/caseManage_chap1.htm.

30. U.S. Environmental Protection Agency. Consumer factsheeton: nitrates/nitrites. 2005. http://www.epa.gov/safewater/dwh/c-ioc/nitrates.html.

31. U.S. Environmental Protection Agency. Indoor air—radon:health risks. 2005. http://www.epa.gov/radon/healthrisks.html.

32. National Research Council. Risk assessment of radon indrinking water. Washington, DC: National Academies Press;1999. http://books.nap.edu/books/0309062926/html/index.html.

33. Agency for Toxic Substances and Disease Registry. Casestudies in environmental medicine: radon toxicity. Atlanta:U.S. Department of Health and Human Services; 2000.ATSDR-HE-CS-2001-0006. http://www.atsdr.cdc.gov/HEC/CSEM/radon/index.html.

34. Darby S, et al. Radon in homes and risk of lung cancer: col-laborative analysis of individual data from 13 Europeancase–control studies. BMJ 2005;330(7485):223.

35. Meza MM, et al. Developmentally restricted genetic deter-minants of human arsenic metabolism: association betweenurinary methylated arsenic and CYT19 polymorphisms inchildren. Environ Health Perspect 2005;113(6):775-81.

36. World Health Organization. Arsenic in drinking water.Geneva, Switzerland: The Organization; 2001. Fact sheetNo. 210. http://www.who.int/mediacentre/factsheets/fs210/en/index.html.

37. National Sanitation Foundation International. Contaminantguide—arsenic. 2004. http://www.nsf.org/consumer/drinking_water/contaminant_arsenic.asp?program=WaterTre.

38. U.S. Environmental Protection Agency. Private drinkingwater wells. 2005. http://www.epa.gov/safewater/privatewells/index2.html.

39. U.S. Environmental Protection Agency. Drinking waterfrom household wells. Washington, DC: The Agency; 2002.EPA 816-K-02-003. http://www.epa.gov/safewater/privatewells/booklet.

GENERAL PURPOSE: To provide registered professionalnurses with current information on types of contaminantsof drinking water, offer guidelines for assessment whencontamination is a suspected cause of illness, and presentpatient education strategies.LEARNING OBJECTIVES: After reading this article and tak-ing the test on the next page, you will be able to• discuss the various disease-causing organisms found

in drinking water, profiling the sources, affected popu-lations, and manifestations of illness.

• outline the diseases and manifestations caused bychemical contamination of water supplies.

• make specific recommendations for identifying andpreventing contamination of drinking water.

TEST INSTRUCTIONSTo take the test online, go to our secure Web site atwww.nursingcenter.com/CE/ajn.To use the form provided in this issue, • record your answers in the test answer section of

the CE enrollment form between pages 48 and 49.Each question has only one correct answer. Youmay make copies of the form. Test code AJN2205.

• complete the registration information and courseevaluation. Mail the completed enrollment form andregistration fee of $26.00 to Lippincott Williamsand Wilkins CE Group, 2710 Yorktowne Blvd.,Brick, NJ 08723, by November 30, 2007. You willreceive your certificate in four to six weeks. Forfaster service, include a fax number and we willfax your certificate within two business days ofreceiving your enrollment form. You will receiveyour CE certificate of earned contact hours and ananswer key to review your results. There is no mini-mum passing grade.

DISCOUNTS and CUSTOMER SERVICE• Send two or more tests in any nursing journal published

by Lippincott Williams and Wilkins (LWW) together,and deduct $0.95 from the price of each test.

• We also offer CE accounts for hospitals and otherhealth care facilities online at www.nursingcenter.com. Call (800) 787-8985 for details.

PROVIDER ACCREDITATIONThis continuing nursing education (CNE) activity for 4contact hours is provided by LWW, which is accreditedas a provider of continuing nursing education by theAmerican Nurses Credentialing Center’s Commission onAccreditation and by the American Association ofCritical-Care Nurses (AACN 00012278, CERPCategory O). This activity is also provider approved bythe California Board of Registered Nursing, providernumber CEP 11749 for 4 contact hours. LWW is alsoan approved provider of CNE in Alabama, Florida, andIowa, and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its homestudy activities are classified for Texas nursing continuingeducation requirements as Type 1. Your certificate isvalid in all states. This means that your certificate ofearned contact hours is valid no matter where you live.

EARN CE CREDIT ONLINEGo to www.nursingcenter.com/CE/ajn and receive a certificate within minutes.

CE4Continuing Education

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