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Drinking Water Overview
[courtesy of American Nursing Association]

Water is essential to life and comprises 60% to 70% of body weight. Children drink more water per body weight than adults. While the United States has made great efforts to provide safe and healthy water, not all drinking water is contaminant-free. Children, because of their special physiologic vulnerabilities and increased consumption of water, may be particularly sensitive to contaminants found in their drinking water. Contaminants may be microbial (virus, bacteria, protozoa), chemical, or radiologic. Nurses need to be aware of the quality of their patients' and community's drinking water and counsel those patients who may be more vulnerable to the contaminants in their water.

Millions of pounds of potentially hazardous industrial and agricultural chemicals are released into the environment each year in the United States. Some of the releases are intentional and some are accidental. Our drinking water, which is derived either from surface waters or from underground sources, are vulnerable to contamination from the pollutant releases, including agricultural and household chemicals, industrial waste, and uncontrolled releases from leaking underground storage tanks and landfills.^[34] Preventing source-water contamination should be incorporated as a community education concern.

In addition to chemical contaminants, pathogenic microbes account for an estimated 900,000 waterborne infections annually.^[35] The majority of waterborne disease incidence may be underestimated because not all outbreaks are recognized, investigated, or reported. Children exposed to microbial contaminants in drinking water may experience a range of gastrointestinal symptoms depending on their immune status and virulence of the microbe. Symptoms range from mild gastric distress to explosive diarrhea. Several microbial contaminants cause more than gastrointestinal symptoms. Exposure to the Coxsackie and ECHO viruses can lead to meningitis and encephalitis. In 1999, an outbreak of E coli 0157:H7 from contaminated drinking water led to 9 deaths in New York from toxic hemolytic uremic syndrome.

Chemical contaminants of particular concern for children include pesticides, heavy metals, nitrates, and disinfection by-products. Infants under the age of 6 months who are exposed to elevated levels of nitrites in drinking water (due to contamination from fertilizer use or sewage runoff) are at risk for developing "blue baby syndrome" (methemoglobinemia), a rare but life-threatening illness. Nurses, as primary health providers in the community, must be able to field questions about water quality and guide vulnerable populations to informed decisions.

The introduction of disinfectants to the drinking water supply was one of the greatest public health successes of the 20th century. Public drinking water is often disinfected by the addition of chlorine to the water during the treatment process. Although chlorine is effective in controlling many microorganisms, it forms organic chlorine compounds, referred to as disinfection byproducts, when it reacts with organic matter found in water distribution pipes. Epidemiologic studies indicate that there may be an increased risk of miscarriage in women and developmental effects to the fetuses of pregnant women exposed to high levels of these by-products.^[36-38]

Although lead paint and dust are the primary sources of exposure to lead, lead in drinking water can contribute up to 20% of this amount. Lead can leach out of household plumbing (lead pipes and lead solder) or from older public water distribution pipes made of lead. In addition, boiling water for more than 1 minute may raise the concentration of lead and other heavy metals present in the water.

If lead is found in drinking water there are several options that should be considered:

• First, have blood lead level tests performed on any children living in the home. Attempt to identify and eliminate the source;

• Do not use water containing lead for mixing a baby's formula;

• Consider a water treatment device or an alternative drinking water source;

• Reverse osmosis treatment devices will remove approximately 85% of the lead; distillation systems can remove about 99%. If these systems are used, then all water used for drinking or cooking must come from the treated faucet (See Related Resources for Lead Distillation Systems);

• Replace lead pipes and solder;

• If it is not feasible to remedy or if a temporary solution is needed, then flushing the water system before using the water for drinking or cooking may be an option. If the water from a particular faucet has not been used for several hours, the cold-water tap should be run until it becomes as cold as it will get. Each faucet should be flushed before using. This may not be an effective method in high-rise buildings; and

• Avoid cooking with or consuming water from hot water taps because hot water dissolves lead more readily than cold.

A 1996 Amendment to the Safe Drinking Water Act allows consumers and their healthcare providers to have access to information concerning the quality of their drinking water. This Amendment requires public water system providers to produce and make available to consumers a Right to Know or Consumer Confidence Report (CCR). These reports are issued annually and must provide information on how to contact the water provider; the source of drinking water (river, reservoir, aquifer); any contaminants detected and their health effects; and compliance with federal drinking water standards. If people have not received their reports, they can call their water company or talk with their landlord to receive a copy. The reports include a recommendation for people with compromised immune systems to consult with their healthcare provider regarding appropriate precautions to take to avoid infection in the event of microbial contamination. Therefore, it is important to be informed about drinking water and who is more susceptible to microbial illness. The EPA has a Web site where many local CCRs can be found (see Related Resources for EPA Safe Water). A water supplier must notify its customers by newspaper, mail, radio, TV, or hand-delivery if water does not meet EPA or state standards or if there is a waterborne disease.

Largest Waterborne E coli O157:H7 Outbreak in United States History

In September 1999, 3-year-old Rachel Aldrich died after being infected with the toxic E coli O157:H7 strain at a New York county fair. Hundreds of others, including Rachel's sister, Kaylea, became ill as well. The New York Department of Health identified 71 people who were hospitalized during the outbreak. Of these, 14 developed hemolytic uremic syndrome, a severe complication of E coli O157:H7 infection that can lead to kidney failure. An investigation by epidemiologists identified 781 persons with confirmed or suspected illness (persons who developed symptoms) related to this outbreak. Of these, 127 cases of E coli and 45 cases of Campylobacter were confirmed by culture. (See Related Resources for International Bottled Water Association.)

Alternative Sources of Drinking Water

When a water source is considered unsafe because of a chemical, microbial, or radionuclide contamination, or because an individual is considered too vulnerable to drink tap water, tap water should be avoided. Alternatives include boiled water, bottled water, and treated or filtered water.

Boiled water. Most harmful microbes found in water will be killed if water is allowed to reach a full rolling boil for 1 minute. However, boiling water for more than 1 minute may concentrate some chemicals (such as lead, arsenic, and nitrates) and may cause some chemical contaminants to be released in the steam where they then can be inhaled.

Bottled water. More than half of all Americans drink bottled water; about a third of the public consumes it regularly. The National Resource Defense Council ^[39] completed a 4-year study to evaluate the quality of bottled water. They found that bottled water regulations are inadequate to assure consumers of safety. At least a third of the bottled water tested violated a state standard or guideline for microbials. The FDA is responsible for good manufacturing practices for bottled water; however, it does not have jurisdiction over intrastate commerce of bottled water, which exempts roughly 60% to 70% of bottled water from FDA regulation. In addition, FDA regulations do not apply to carbonated water. The following organizations can provide information on bottled water:

• NSF International (877-8-NSF-HELP)

• International Bottled Water Association (see Related Resources)

Water filters. There are a variety of water treatment units on the market. No one filter removes all sources of contamination; therefore, it is important to identify the contaminant(s) of concern before recommending or investing in a filtration device for the home. For help in picking a unit, contact either of the independent nonprofit organizations listed below. (Water treatment units certified by these organizations will indicate certification on their packaging labels.)

• NSF International (877-8-NSF-HELP) tests and certifies home water treatment units

• Water Quality Association (630-505-0160; see Related Resources for Web site) classifies units according to the contaminants they remove and also lists units that have earned its approval.

• Underwriters Laboratory (see Related Resources for Web site) also certifies some home water treatment units.

Tap Water Testing

Although public water utilities are required to test for regulated contaminants and report the results, there may be instances when consumers may want additional information. For example, consumers may want to check for lead in the water. Water utilities are not required to check the lead level at each end point. In addition, most states have some regulations regarding the water testing of new wells; however, there are seldom requirements for periodic retesting. Private wells are not regulated by the EPA as public utilities are, although EPA does recommend that private wells be tested annually.

The right to know statutes do not apply to personal wells. Therefore, consumers with private wells should have them checked annually for bacteria and some chemical contaminants, such as nitrates. Information for private well owners about how to protect a private water supply, as well as links to a list of state-certified drinking water laboratories, can be found in Related Resources for EPA, Info on Private Wells. In addition, most state health departments can provide a list of state-certified independent water testing laboratories. Prices for water testing vary according to the type and number of contaminants being detected.

NSF International

NSF International is an organization that tests and verifies that products they certify meet all of the requirements of specified standards and that manufacturers' claims are true. NSF does not recommend, rate, or compare products. An NSF mark indicates assurances that the product will perform as claimed. NSF will issue certification to water bottlers that meet the basic FDA requirements. If the product meets the NSF standards, the bottled water label should indicate the certification. In addition, NSF will issue certifications for water treatment devices if they meet NSF standards. More information about this service can be found at the NSF Web site (see Related Resources).

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