www.ohd.hr.state.or.us/dwpVol.17, Issue 2 � SPRING 2002

Protecting Public Health by Assuring Safe Drinking Water

(Continued on page 2)

PART I REPORT -WALKERTON DISEASE OUTBREAK

by The Honourable Dennis R. O’Connor

The Walkerton outbreak in Canada (May 2000) sickened2,300 people, and seven people died. The Part I Report of theofficial inquiry into the May 2000 waterborne diseaseoutbreak was recently released. The Report was authored bythe Honourable Dennis R O’Connor, Justice of the Court ofAppeal for Ontario, Canada. The Background and Summaryof Conclusions from that report are reproduced here. Theyillustrate what can happen when basic public health protec-tions break down, and remind us why our collective atten-tion to drinking water safety is so important. We encourageyou to view the full report at www.walkertoninquiry.com .This is required reading for all drinking water professionals!- Dave Leland, PE

BackgroundUntil May 2000, there was little to distinguish Walkertonfrom dozens of small towns in southern Ontario. It is apretty town, located at the foot of gently rolling hills, alongthe banks of the Saugeen River. Walkerton traces itshistory back to 1850, when Joseph Walker, an Irish settler,built a sawmill on the river, starting a settlement thatadopted his name. In time, it became the county seat forBruce County. The name survived an amalgamation in1999, when Walkerton was joined with two farmingcommunities to form the Municipality of Brockton.Walkerton has kept its small-town look and feel. Many ofits 4,800 residents make their living from businesses thatserve the surrounding farms.

In May 2000, Walkerton’s drinking water system becamecontaminated with deadly bacteria, primarily Escherichiacoli O157:H7. Seven people died, and more than 2,300became ill. The community was devastated. The losseswere enormous. There were widespread feelings offrustration, anger, and insecurity.

The tragedy triggered alarm about the safety of drinkingwater across the province. Immediately, many importantquestions arose. What actually happened in Walkerton?What were the causes? Who was responsible? How could

PROGRAM UPDATE

by Dave Leland

Operator Certification Rules FinalizedThe Oregon operator certification rules are now amendedto meet the EPA Operator Certification Guidelines. Thisbrings to successful completion an effort that began wayback in 1998! The amended rules are now available on thewebsite. Meeting the EPA guidelines made the followingchanges to the Oregon program necessary:

� Eliminated exemptions from certification for opera-tors of small groundwater systems, and those systemssupervised by registered Professional Engineers,

� Required that appropriately certified operators arepresent or available at all times that operationaldecisions are made that affect public health, and

� Eliminated the “Operator-in Training” designation,which allowed operators to write certification examswithout meeting experience qualifications.

These changes are not trivial, and some water suppliersin Oregon will need to make adjustments to meet them.We understand that change will take time. We encourageeach water supplier to evaluate their operational organi-zation and certification status, determine their needswith respect to the new requirements, and begin to movetoward meeting those needs. Change is already evident -record numbers of operators are writing the May examsand applying for initial certification.

We are working with the Drinking Water AdvisoryCommittee to review suggestions received from watersuppliers about the experience and education require-ments, particularly with respect to Water Distribution

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INSIDE THIS ISSUE:

Youngs River Lewis & Clark WD .......................... 3How to Fill Out a Lab Slip .................................... 5Training Calendar .................................................. 6

Spring 2002 � Page 2

WALKERTON (continued from page 1)

this have been prevented? Most importantly, how do wemake sure this never happens again?

The government of Ontario responded by calling thisInquiry. I have divided the mandate of the Inquiry into twoparts. The first, which I refer to as Part 1, relates only to theevents in Walkerton. It directs me to inquire into the circum-stances that caused the outbreak - including, very impor-tantly, the effect, if any, of government policies, procedures,and practices. The second, Part 2, goes beyond the events inWalkerton, directing me to look into other matters I considernecessary to ensure the safety of Ontario’s drinking water.The overarching purpose of both parts of the Inquiry is tomake findings and recommendations to ensure the safety ofthe water supply system in Ontario.

Because of their importance to the community, thehearings for Part 1 were held in Walkerton. Over thecourse of nine months, the Inquiry heard from 114witnesses, including residents of the town, local officials,senior civil servants, two former ministers of the environ-ment, and the Premier. The report summarized hereoutlines my findings and recommendations for Part 1 ofthe Inquiry.

The Part 2 process has also been completed, and I expect todeliver my report for Part 2 in approximately two months.

I would encourage those who are interested to read thereport in full. For convenience, however, this summaryprovides a brief review, in point form, of my most signifi-cant conclusions.

Summary of Conclusions� Seven people died, and more than 2,300 became ill.

Some people, particularly children, may endurelasting effects.

� The contaminants, largely E. coli O157:H7 andCampylobacter jejuni, entered the Walkerton systemthrough Well 5 on or shortly after May 12, 2000.

� The primary, if not the only, source of the contami-nation was manure that had been spread on a farmnear Well 5. The owner of this farm followedproper practices and should not be faulted.

� The outbreak would have been prevented by the useof continuous chlorine residual and turbiditymonitors at Well 5.

� The failure to use continuous monitors at Well 5resulted from shortcomings in the approvals andinspections programs of the Ministry of the Envi-ronment (MOE). The Walkerton Public UtilitiesCommission (PUC) operators lacked the trainingand expertise necessary to identify either the vulner-

ability of Well 5 to surface contamination or theresulting need for continuous chlorine residual andturbidity monitors.

� The scope of the outbreak would very likely havebeen substantially reduced if the Walkerton PUCoperators had measured chlorine residuals at Well 5daily, as they should have, during the critical periodwhen contamination was entering the system.

� For years, the PUC operators engaged in a host ofimproper operating practices, including failing to useadequate doses of chlorine, failing to monitor chlorineresiduals daily, making false entries about residuals indaily operating records, and misstating the locations atwhich microbiological samples were taken. Theoperators knew that these practices were unacceptableand contrary to MOE guidelines and directives.

� The MOE’s inspections program should havedetected the Walkerton PUC’s improper treatmentand monitoring practices and ensured that thosepractices were corrected.

� The PUC commissioners were not aware of theimproper treatment and monitoring practices of thePUC operators. However, those who were commis-sioners in 1998 failed to properly respond to anMOE inspection report that set out significantconcerns about water quality and that identifiedseveral operating deficiencies at the PUC.

� On Friday, May 19, 2000, and on the days following,the PUC’s general manager concealed from theBruce-Grey-Owen Sound Health Unit and othersthe adverse test results from water samples taken onMay 15 and the fact that Well 7 had operatedwithout a chlorinator during that week and earlierthat month. Had he disclosed either of these facts,the health unit would have issued a boil wateradvisory on May 19, and 300 to 400 illnesses wouldhave been avoided.

� In responding to the outbreak, the health unitacted diligently and should not be faulted forfailing to issue the boil water advisory beforeSunday, May 21. However, some residents ofWalkerton did not become aware of the boil wateradvisory on May 21. The advisory should havebeen more broadly disseminated.

� The provincial government’s budget reductions ledto the discontinuation of government laboratorytesting services for municipalities in 1996. In imple-menting this decision, the government should haveenacted a regulation mandating that testing laborato-ries immediately and directly notify both the MOEand the Medical Officer of Health of adverse results.

Spring 2002 � Page 3

NEW MEMBRANE FILTER FOR YOUNGSRIVER LEWIS AND CLARK WD

by Kari Salis

Youngs River Lewis and Clark Water District (YRLCWD)serves 2500 people in Clatsop County, just south of Astoria.They use the North and South Forks of the Barney Creek astheir water source and treated the water with chlorine butno filtration. In 1992, they were ordered to install filtrationin accordance with the Surface Water Treatment Rule.YRLCWD experienced frequent turbidity spikes greaterthan 5 NTU, and boil water notices were so common thatfold-down signs were installed on every road into theservice area (see photo).

Fold-down signs frequently advised residents to boil theirunfiltered water when turbidity was high.

Ric Saavedra, Treatment plant operator, in front of themembrane filter system.

In order to be approved in Oregon, membrane filters mustbe certified by a third party, and live cyst challenge studiesmust show at least 2-log removal for giardia and crypto.In December 2001, construction was completed on a Pall-Microza Membrane filter plant at YRLCWD. Up to 300gallons per minute goes through a 100 micron strainerand then through one of 24 membrane filter modules,each containing 6500 membrane strands. The filters arebackwashed every 12,000 gallons or more frequently if the

turbidity is high. Integrity testing is done weekly on eachmodule. No chemicals are used except for an occasionalchemical cleaning of the membranes, which happenswhen the transmembrane pressure reaches 30 psid. Thissystem may require cleaning as little as once per year.

Particle counters and turbidimeters are present on theinfluent and effluent flows. Finished water turbidity istypically 0.02 NTU, and particle counters (set to measureanything above 0.2 micron) are usually 0. Water qualityfrom the membrane filter is clearly far superior to theunfiltered water. The district has been able to remove theirroadside boil water signs, and operation of the new plant isso simple that the operators can spend more time on othertasks. This is an excellent example of a new technology thatcan provide a significant public health benefit that is stillcost-effective and operator-friendly.

Kari Salis, PE, is in the Technical Services Unit of the DrinkingWater Program / (503) 731-4317 or karyl.l.salis@state.or.us

Had the government done this, the boil water advi-sory would have been issued by May 19 at the latest,thereby preventing hundreds of illnesses.

� The provincial government’s budget reductionsmade it less likely that the MOE would have identi-fied both the need for continuous monitors at Well5 and the improper operating practices of theWalkerton PUC.

� The Part 1 report contains some recommendationsdirected toward ensuring the safety of drinkingwater in Ontario. However, the majority of myrecommendations in that respect will be in the Part2 report of this Inquiry.

* Just out—part 2 of the Walkerton Inquiry is now available at:www.walkertoninquiry.com

Spring 2002 � Page 4

certification. The DWAC will identify any changesneeded here to meet water supplier and operator needswhile maintaining compliance with the EPA guidelines.

Water System SecuritySecurity issues continue to command attention. Largewater suppliers around the U.S. recently applied foravailable security grants from EPA, and will be using thosefunds to conduct security assessments of their watersystems. This includes all six large water suppliers inOregon. In Oregon, the first of our one-half day securityworkshops was held in Rockaway Beach in collaborationwith the Oregon Association of Water Utilities. The focushere is on security related to small and medium-sizedpublic water systems. Participants receive a copy of the“Water System Security-A Field Guide” recently publishedby the American Water Works Association. Look for fiveadditional sessions around the state over the next year.Contact Kurt Putnam of the Drinking Water Program formore information (503-731-4317).

At the recent annual conference of the Pacific NorthwestSection-American Water Works Association held in Eugene,security was the focus of a compelling keynote address byJack Hoffbuhr, Executive Director of AWWA in Denver,Colorado. Jack promoted the “3 Cs” of security - culture,coordination, and communication. Collectively, we mustinstall a sense of security into the culture of our watersupply organizations as a core value. Security must be animportant part of everyone’s job, all the time. We mustcoordinate with others who play important roles in security,including public safety, emergency responders, public healthofficials, and the medical community. This coordinationshould be carried out through an up-to-date and practicedemergency response plan. Finally, we must communicateeffectively with the public, media, and other agencies. Don’tlet the first communication be in a crisis! Good words ofwisdom for all of us in the drinking water profession.

PROGRAM UPDATE (continued from page 1) Walkerton Outbreak Inquiry FindingsPart One of the Report of the Walkerton Inquiry wasrecently published. The summary of conclusions isreproduced beginning on page 1 of this newsletter.

Safe Drinking Water Information System(SDWIS-State)Program staff have been hard at work implementing theSDWIS-State data management system, developed by EPAfor use by the state drinking water programs. This willreplace our current system that has served us well, but isreally past due for replacement and upgrade. SDWIS-Statewill significantly improve our capability to track compliancewith the coliform regulations, at a full level of detail. So, it isnow more important than ever for water suppliers to reporton-time, and at the necessary level of detail. We have revisedthe coliform test result report form accordingly (see articleon page 5), as well as the coliform summary report form.We are well into gearing up the chemical compliancemodule of the new database, beginning with nitrate moni-toring schedules. As time goes on, more and more of thedata you see presented on the website (“Data On-line”) willbe generated from SDWIS-State. Additional data systemcapabilities are contained in the next release of SDWIS-State, expected from EPA in early fall.

2003 LegislatureKey statutory and budget issues for the program andwater suppliers are beginning to shape up for the 2003Legislative Assembly. Discussions of agency budgetrequests are likely to have a particularly keen edge, giventhe state of the economy. Issues likely to reappear fromthe 2001 Legislature include expanding the drinkingwater program capacity to adequately implement andoversee all those new federal drinking water standards,and the direct reporting of water test results from labs tothe program. Both of these issues relate to the findings ofthe Secretary of State Audit Report on the drinking waterprogram, released during the 2001 session.

Dave Leland, PE, is Manager of the Drinking Water Program/ (503) 731-4010 or david.e.leland@state.or.us

Spring 2002 � Page 5

HOW TO FILL OUT A LAB SLIP

by Mary Alvey

1. Public Water System ID# - enter the ID number forthe system being sampled

2. Name of Water System – enter the name of thesystem being sampled

3. County – enter the county where the water systemis located

4. Phone – enter the phone number that the lab shouldcall if they have questions about the sample or if theyneed to report a positive result

5. Collection Date – enter the date that the samplewas collected

6. Collection Time – enter the time that the sample wascollected, and circle either AM or PM

7. Type of Sample – mark the appropriate box� Routine – mark this box if the sample is a regular

routine sample� Repeat – mark this box if the sample was collected

because of a positive routine sample result (see #9)� Special – mark this box if the test results are not

representative of water people are drinking.Results do not need to be sent to the DrinkingWater Program. This could be used for samplescollected after disinfecting a new water line orprior to reopening a seasonal facility

8. Date of the initial positive – if the sample wascollected as a repeat, then enter the date that thepositive routine sample was collected. Otherwiseleave blank

9. For Repeat samples – indicate if this sample wascollected at the same site as the positive routine, upstream or down stream from the routine site orother site

10. Collected By – enter the name of the person collect-ing the sample

11. Sample Point – enter a description of the samplelocation, such as “123 Main St., hose bib” or “Well#2, sample tap”

12. Chlorinated? – mark yes if the system is chlorinated,no if it is not

13. Free Chlorine – if the system is chlorinated, use aDPD test kit to measure the free chlorine residual atthe site where the sample is collected, and enter theresult. If the sample is being collected at a pointbefore chlorination, leave this space blank

14. Return Address – enter the address that the testresult is to be mailed to

Mary Alvey, RS, is Unit Manager of the Monitoring &Compliance Unit of the Drinking Water Program /(503) 731-4381 or mary.b.alvey@state.or.us

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PIPELINE is intended to provide usefulinformation on technology, training, andregulatory and policy issues to those involvedwith the state’s public water systems to improvethe quality of drinking water in Oregon.PIPELINE may be copied or reproducedwithout permission provided credit is given.

IF YOU WOULD LIKE THIS IN AN ALTERNATE FORMAT, PLEASE CALL (503) 731-4010

PIPELINE is published quarterly freeof charge by the staff of the Department ofHuman Services, Drinking Water Section,800 NE Oregon St., Portland OR 97232,Phone (503) 731-4010. Periodicals postagepaid at Portland OR.POSTMASTER: Send address changes toPIPELINE, P.O. Box 14450,Portland OR 97293-0450.

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Department of Human ServicesDrinking Water ProgramP.O. Box 14450Portland OR 97293-0450

Oregon Association of Water Utilities(503) 873-8353Aug. 6 Water System Emergency

Response Planning &Security

Aug. 20 SDWA Update &Monitoring Requirements

Sept. 23 Source Water Protection

Cross Connection/Backflow CoursesBackflow Management Inc. (B) (503) 255-1619Clackamas Community College (C) (503) 657-6958 ext. 2388OAWU (O) (503) 873-8353

Backflow Assembly Tester CourseSept. 16-20 Oregon City (C)Sept. 16-20 Portland (B)

Backflow Assembly Tester RecertificationSept. 27 Oregon City (C)

Cross Connection Inspector CourseJul. 22-25 Portland (B)

Water System Training CourseDepartment of Human ServicesMarsha Fox/(503) 731-4899Jul. 30 EugeneAug.* Pendleton, Klamath FallsSept.* Bend*Dates to be announced