Drinking Water
Information
for Health
Care Providers
Supplemental Materials:
• Accreditation, Designation, and
Disclosure Statements and Learner
Participation
• How to Apply for Continuing
Education Credit
• Objectives
• Key Concepts
• Drinking Water Resources
• Additional Resources for Health
Professionals
• Acknowledgements
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Accreditation, Designation, and Disclosure
Statements and Learner Participation 1
How to Apply for Continuing
Education Credit 4
Objectives 6
Key Concepts 7
Drinking Water Resources 15
Additional Resources for Health
Professionals 20
Acknowledgements 23
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Accreditation, Designation,
and Disclosure Statements
and Learner Participation
The educational activity was developed by the
Centers for Disease Control and Prevention
(CDC) and the United States Environmental
Protection Agency (EPA).
Use of trade names or commercial sources is
for informational purposes only and does not
constitute an endorsement by the United States
Department of Health and Human Services, the
Public Health Service, or EPA.
Views expressed by guest participants are not
necessarily the views of the CDC or EPA.
This activity has been planned and implemented
in accordance with the Essential Areas and
Policies of the Accreditation Council for
Continuing Medical Education (ACCME) through
the joint sponsorship of the CDC and EPA. The
CDC is accredited by the ACCME to provide
Continuing Medical Education for physicians.
The CDC designates this educational activity
for 1.25 Category 1 credit toward the American
Medical Association Physician's Recognition
Award. Each physician should claim only those
credits that he or she actually spent in the activity.
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This activity for 1.2 Contact Hours is provided
by the CDC, which is accredited as a provider of
Continuing Education in Nursing by the American
Nurses Credentialing Center's Commission on
Accreditation.
The CDC has been approved as an Authorized
Provider of Continuing Education and Training
programs by the International Association for
Continuing Education and Training and awards
0.1 Continuing Education Units.
The CDC is a designated provider of Continuing
Education Contact Hours in Health Education by
the National Commission for Health Education
Credentialing, Inc. This program is a designated
event for the Certified Health Education Specialist
to receive 1.0 Category I Contact Hour in Health
Education, CDC provider number GA0082.
The CDC and our presenters wish to disclose they
have no financial interests or other relationships
with the manufacturers of commercial products,
suppliers of commercial services, or commercial
supporters of this Continuing Education activity.
Presentations will not include any discussion of
the unlabeled use of a product or a product under
investigational use.
Viewers may participate in the learning
experience by emailing questions and comments
to the organizations and associations listed in the
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Resources sections of this booklet, and by using
their websites.
CE credit is available only through CDC/ATSDR's
website, "Training and Continuing Education
Online," at www.phppo.cdc.gou/phtnonline. See
the instructions on the following page to learn
how to register for credits.
The origination date of this educational activity is
May 13, 2004. Continuing Education Credit for
these Enduring Materials will expire on May 12,
2007.
CDC Continuing Education Activity Numbers:
VHS format: VC 0070
DVD format: DV 0001
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How to Apply for Continuing
Education Credit
Continuing Education (CE) Credits are available
for various professions through CDC/ATSDR's
Training and Continuing Education OnLine
System based on 62 minutes of instruction (1.25
CME, 1.2 CNE, .1 CEU, 1.0 CECH).
Follow these 4 easy steps to obtain CE Credit:
1. Go to the Training and Continuing Education
OnLine Website (www.phppo.cdc.gov/
phtnonline) OR link to the site from
www.epa.gov/safewater/healthcare. If you
have never used this system, you will
need to create a Profile and establish a
login ID and password. At the home page,
www.phppo.cdc.gov/phtnonline. click on New
Participant and follow the prompts.)
2. One you have created a Profile go to the
home page of www.phppo.cdc.gov/phtnonline
and click on Participant Login. When the
yellow box appears, put in your login and
password. It will lead you to a Participant
Services page with 4 icons that will allow you
to move about in the system as you wish.
3. Click on the Search and Register icon and
register for this particular course so the
system knows what to give you credit for. You
can search by 3 different options: using the
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title, "Tap Into Prevention: Drinking Water
Information for Health Care Providers," or
using the course number VC 0070 or DV
0001, or using the key words "drinking
water."
4. Return to the "icon" page by looking to the
left of the screen in the gray shaded area
and click on Participant Services. Click on
the Evaluation and Tests icon and follow the
prompts to complete the evaluation. The
system will then give you an opportunity to
print out your certificate.
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Objectives
After watching this video, you will be able to:
• Name four health problems related to
contaminants in drinking water
• Identify the types of patients most sensitive to
each health problem
• Describe how contaminants can enter
drinking water supplies
• Identify the treatment methods that remove
the contaminants
• List clinical findings that should prompt
reporting suspicion of a waterborne disease to
the local health department
• Describe how patients can learn about the
quality of their drinking water
• Describe the role of health care providers in
a public health network that identifies and
responds to waterborne illness
• List resources for further information on
drinking water and health
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Key Concepts
The following information represents some
contaminants to which certain patients may be
particularly sensitive.
Cryptosporidium parvum. Cryptosporidium
paruum is a pathogen found in human and animal
fecal waste. It can enter the rivers, lakes and
streams and rarely, ground water that contribute
to drinking water supplies. Because of it's small
size and composition, it is resistant to typical
filtration and disinfection methods—though
EPA has tightened its standards in recent years
requiring public water systems specifically to
address this contaminant.
• Exposure to Cryptosporidium parvum in
drinking water may cause gastrointestinal
problems, such as diarrhea, vomiting, and
cramps. Patients whose immune systems
are weakened by AIDS, chemotherapy,
a recent transplant or other reasons are
most vulnerable. Diarrhea and vomiting
may cause infants and the frail elderly to
become dehydrated more quickly. In most
healthy adults and children, the problems
are temporary. Other, more common
routes of exposure to this pathogen are
food, unsanitary diaper-changing practices,
person-to-person-contact, and swimming in
contaminated water.
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« Suggested interventions: Sample stools
more frequently. Include questions on water
sources for patients with diarrhea. Those
with questionable water sources require
further investigation. Most standard ova and
parasite cultures do not automatically test
for Cryptosporidium. Be sure to specifically
request an acid-fast fluorescent test.
Escherichia colt or E. coli. E, coli is a type
of fecal coliform bacteria commonly found in the
intestines of animals and humans. The presence
of E. coli in water is a strong indication of recent
sewage or animal waste contamination. Sewage
may contain many types of disease-causing
organisms. Although most strains of E. coli are
harmless and live in the intestines of healthy
humans and animals, a particular strain, E. coli
0157-.H7, produces a powerful toxin and can
cause severe illness.
« Most infections of E. coJi O157:H7 are
believed to have come from eating
undercooked ground beef. However, some
have been waterborne, and people have
become sick after drinking contaminated
water.
• Infection by E. coli 0157:H7 is characterized
by severe bloody diarrhea and abdominal
cramps, although sometimes the infection
causes non-bloody diarrhea, often with
no fever. In some people, particularly
children under 5 years of age and the
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elderly, the Infection can also cause
a life-threatening complication called
hemolytlc luremlc syndrome, in which
the red blood cells are destroyed and the
kidneys fail. Hemolytic uremic syndrome is
usually treated in an intensive care unit, and
blood transfusions and kidney dialysis are
often required.
« Suggested interventions: Encourage patients
(or their parents) to have household well
water tested annually for nitrates and
bacteria by a state-certified laboratory. If a
patient's well tests positive for E, coli, people
in the household should not drink the water
without boiling it for at least one minute
at a rolling boil—longer if they live at high
altitudes. The well may also be disinfected
according to procedures recommended by
the local health department. Water must be
monitored periodically after disinfection to
make certain the problem does not recur.
If contamination is a recurring problem,
patients should investigate the feasiblity
of drilling a new well or installing a point-
of-entry disinfection unit using chlorine,
ultraviolet light, or ozone.
Disinfectants and Disinfection Byproducts
(DBPs). Disinfectants, while effective in
controlling many microorganisms, react with
matter in water to form DBPs. Unchlorinated
private well water is unlikely to contain any DBPs.
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« While health effects from exposure to
disinfectants and DBFs vary by contaminant,
some epidemiological studies have shown
a link between bladder, rectal, and colon
cancers and DBF exposure. Additionally,
human epidemiological studies report an
association between chlorinated drinking
water and reproductive and developmental
endpoints such as spontaneous abortion,
neural tube defects, pre-term delivery,
intrauterine growth retardation, and low
birth weight. In August 2003, EPA proposed
measures beyond those already required for
public water systems.
• Suggested interventions: Drinking plenty of
water from a safe source during pregnancy
is important. If your patients' public water
system has notified customers of a DBF
violation, follow instructions from the public
water system. For example, your patients
might want to consider alternatives to tap
water during pregnancy.
Lead. Paint chips and dust from lead paint in
old buildings are the primary routes of children's
exposure to lead, but EPA estimates that up to
20 percent of a person's background exposure
may be due to lead in drinking water—and the
percentage is higher for infants drinking formula
mixed with contaminated drinking water. Lead
may be present in drinking water because of
corrosion of household plumbing systems; erosion
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of natural deposits. In some communities, lead
service lines can also contribute to high levels of
lead in drinking water.
• In Infants and young children,
continuous exposure to high levels of
lead may result In delays In physical
or mental development, deficits
In attention span, and learning
disabilities.
« For adults, such exposure may result in
kidney problems or high blood pressure.
• Suggested interventions: Look for symptoms
of lead poisoning in children, and test
infants' blood lead levels. If a child's blood
lead level is high, consider lead in tap water
as a possible factor, in addition to lead
paint exposure. Encourage patients to have
drinking water tested for lead in homes,
schools, and day care centers by a state-
certified laboratory. Encourage local schools
and day care centers to test their drinking
water outlets for lead.
* Use only cold water for drinking, cooking,
and especially making baby formula. It's
important to consider that foods that absorb
all of the water in the pot, such as rice and
dried beans, will also absorb all of the lead
that is in the cooking water. Soups made or
mixed with water will also contain any lead
that's in the water. Foods cooked in water
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and then drained, such as pasta, meat, or
vegetables, also absorb some lead from the
water.
« If lead levels in drinking water are high,
consider alternatives to using boiled tap
water in baby formula.
« Information and brochures are available
from the National Lead Information Center,
(800) 424-LEAD [5323], www.eDa.aov/lead/
nlic.htm
Nitrates and Nitrites. Nitrates may run off
or percolate into water sources from excessive
fertilizer use and animal waste: leaching from
improperly constructed or maintained septic
tanks, cesspools, sewage; or erosion of natural
deposits.
• Exposure to nitrates in drinking water at
levels above the drinking water standard
may result in methemaglobinemia,
or "blue baby syndrome" in infants
under six months. Blue baby syndrome
is life-threatening without immediate
medical attention. Infants most likely to
get methemoglobinemia are those who are
already sick and consume food that is high
in nitrates, such as spinach, broccoli and
cured meats, and drink formula mixed with
water that is high in nitrates.
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« Possible interventions: Encourage patients to
have household well water tested annually
for nitrates and bacteria by a state-certified
laboratory, especially those caring for infants
and expectant parents and grandparents.
If water has high nitrate levels, consider
alternatives to using boiled tap water in baby
formula. Boiling water only increases nitrate
concentrations.
Drinking Water Security. Events of September
11, 2001, have brought into focus the possibility
of intentional contamination of drinking water and
wastewater infrastructure. Doctors, nurses, and
others in primary care would likely be the first to
observe unusual illness patterns or disease trends
resulting from intentional biological or chemical
contamination.
"Recognizing Waterborne Disease and the Health
Effects of Water Pollution: A Physician On-line
Reference Guide," by Patricia L. Meinhardt,
MD, MPH, MA, includes a section, "Physician
Preparedness for Acts of Water Terrorism."
It is available at WaterHealthConnection.org.
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Recognize, Report, and Prevent
Waterborne Illness
• Report suspicion of waterborne illness to your
local health department.
• Take an environmental health history that
includes, "What is the source of drinking
water?"
• Familiarize yourself with your patients water
supply. Annual water quality reports are a
good first source of information on local
public water systems. Household well owners
are responsible for making sure their wells are
tested regularly and maintained properly. A
free booklet, "Drinking Water from Household
Wells," is available at www.epa.gou/safewater/
oriuatewells/booklet/mdex.html.
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Drinking Water Resources
EPA Office of Ground Water and
Drinking Water
Together with states, tribes, and our many
partners, the Office of Ground Water and
Drinking Water protects public health by ensuring
safe drinking water and protecting ground water.
EPA's Safe Drinking Water Hotline provides
information about drinking water and ground
water protection programs authorized under the
Safe Drinking Water Act. (800) 426-4791
www.epa.gov/safewater
CDC Division of Parasitic Diseases
The mission of the division is to prevent and
control parasitic diseases in the United States and
throughout the world and to increase survival
of children in developing countries, through
surveillance and by conducting laboratory and
epidemiological research.
www.cdc.gou/ncidod/dpd/healthuwater
Home Water Testing
Your state Certification Officer can provide a list
of laboratories certified to test for contaminants in
drinking water.
www.eoa.Qou/safewater/faa/sco.html
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Household Wells
Home*A*Syst
Provides information to help farmers and rural
residents assess pollution risks and develop
management plans to meet their unique needs.
www. wisc.edu/farmasust
Wellcare® Hotline
(888) 395-1033
Through wellcare®, the Water Systems Council
provides rural well owners, other technical
assistance providers, water system operators, and
community leaders important information and
training on how to properly design, operate and
manage well-based systems.
www.watersvstemscouncil.org/wellcare
DrinkWell™ Well Water Testing
Underwriters Laboratories' well testing service
also has a nurse call center and provides
sources of information. For questions regarding
ordering, sample collection and shipping, call
888-503-5544. www.uldrinkwett.com
National Ground Water Association
This National Ground Water Association's
Wellowner web site offers a variety of
information relating to ground water and private
water well systems, www.wellowner.org
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Home Water Treatment Units
Water Quality Association
The Water Quality Association is a not-for-profit
international trade association representing the
household, commercial, industrial, and small
community water treatment industry.
mmm.mqg.org
NSF International
NSF International's Home Water Treatment
Devises web page includes information on
selecting and using water treatment devices.
www.nsfconsumer.org/water/dw_treatment.asp
Underwriters Laboratories
Underwriters Laboratories tests and certifies home
water treatment units to ensure they meet national
standards, www.ul.com/water
Bottled Water
International Bottled Water Association
This trade association requires members to adhere
to its model code, in addition to meeting federal
requirements for bottled water.
www. bottledwater. org
NSF International
NSF International tests bottled water products
for compliance with federal guidelines and lists
bottled water companies certified through its
voluntary certification program.
www.nsfconsumer.orQ/water/bottled water.aso
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Protecting Drinking Water Sources
EPA's Source Water Protection Program
EPA has information on preventing contamination
of streams, rivers, lakes and underground aquifers
that supply private wells and public drinking water.
www.epa.gou/safewater/protect.html
Groundwater Foundation
The Groundwater Foundation educates and
motivates people to care for and about ground
water through water festivals and other activities.
Its Groundwater Guardian program encourages
communities to begin and enhance ground water
awareness and protection activities.
uimm.groundmater.org
American Ground Water Trust
This educational organization protects ground
water and promotes resource sustainability;
communicates the value of ground water;
showcases science and technology solutions;
increases awareness; and facilitates stakeholder
participation in water resource decisions.
uiuiui.aguit.org
Ground Water Protection Council
The Ground Water Protection Council is a
national association of state ground water
and underground injection control agencies
whose mission is to promote the protection and
conservation of ground water resources for all
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beneficial uses, recognizing ground water as a
critical component of the ecosystem.
mmm.Qmpc.org
National Ground Water Association
The National Ground Water Association's mission
is to enhance the skills and credibility of all
ground water professionals, develop and exchange
industry knowledge and promote the ground
water industry and understanding of ground water
resources. umiui.nQuia.org
Water Systems Council
The Water Systems Council is a national non-
profit organization, dedicated to promoting the
wider use of wells as modern and affordable safe
drinking water systems and to protect ground
water resources, www.watersvstemscouncil.ora
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Additional Resources for
Health Professionals
This list is not meant to be exhaustive, but includes
opportunites for further continuing education on
drinking water and resources on environmental
health.
"Recognizing Waterborne Disease and the Health
Effects of Water Pollution," an online reference
guide; up to 22 Continuing Medical Education
credits and continuing education credits for other
professions are sponsored by American College of
Preventive Medicine. By Patricia Meinhardt, MD,
MPH, MA Includes a repository of information on
how to detect biological and chemical weapons
exposure and respond appropriately.
www.waterhealthconnection.org
"Waterborne Disease and Water Pollution: What
Every Physician in Your Community Needs to
Know." This American College of Preventive
Medicine Institute contains 10 presentations by
various physicians and water professionals in
streaming video and audio. Speakers provide a
clinical overview of diagnosis and management
of waterborne disease and health effects of
water pollution, as well as strategies for risk
communication to discuss these environmental
health issues with patients. The sessions also
address challenges facing the water utility
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community, tasked with providing safe drinking
water in America.
www.acpm.org/ehealth/waterborne.htm
Drinking Water and Disease: What Every Health
Care Provider Should Know, Physicians for Social
Responsibility
www.envirohealthaction.orgl upload_Jilesl
dwprimer.pdf
"Environmental Health and Nursing," a
developing educational series designed to
assist nurses integrating environmental health
knowledge and skills in professional practice
through distance learning. CEU and graduate
credits available.
University of Minnesota School of Public Health,
http://mclph.iawshotel.umn.edu/pubh7201
University of Maryland School of
Nursing EnviRN Website
A Virtual Resource for Environmental
Health and Nursing
www.envirn.umaryland.edu
EnviRN's gateway to an array of
resources including multimedia content:
envirn.umarvland.edu/resources/resources.htm
Environmental Health and Nursing Practice, by
Barbara Sattler, RN, DrPH, and Jane Lipscomb,
RN, PhD, FAAN, Editors, www.springerpub.com/
store/page 4282 6.html
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National Environmental Education and Training
Foundation Health Publications
Includes links to information for health
care providers on pesticides, ranging from
national strategies to medical and nursing
practice guidelines. www.neetf.org/Health/
publications.sthm
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Acknowledgements
Co-authors:
John Balbus, MD, MPH, Director,
Environmental Health Program,
Environmental Defense, Washington,
DC; Founding Director, Center for Risk
Science and Public Health, George
Washington University Medical Center
Vince Clews, Screenwriter, Baltimore, MD
Sherri Umansky, Environmental Protection
Specialist, Office of Ground Water and
Drinking Water, U.S. Environmental
Protection Agency, Washington, DC
Narrators:
John Balbus, MD, MPH
Paul Anthony, Actor, Chevy Chase, MD
Featured Experts:
Milwaukee
Paul Bierdrzycki, Manager of Disease Control,
City of Milwaukee Health Department
*Kathleen Blair, RN, Epidemiologist,
City of Milwaukee Health Department
Mary Busalacchi, HIV Nurse Clinician,
Milwaukee
Lon Couillard, Water Qualify Manager,
Milwaukee Water Works
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Ian Gilson, MD, Internist, Milwaukee
Karen Sue Kehl, PhD, Associate Professor and
Section Director, Microbiology, Medical
College of Wisconsin; Technical Director
of Microbiology, Children's Hospital of
Wisconsin
Paul Nannis, Vice President, Department of
Government and Community Relations,
Aurora Health Care; formerly City of
Milwaukee Health Commissioner
Mary Rotar, RN, Infection Control
Coordinator for Children's Health Care
System and formerly for West Allis
Memorial Hospital, Milwaukee
Thomas A. Taft, MD, Infectious Disease
Specialist, Hospital Epidemiologist,
and Chair of Infection Control at West
Allis Memorial Hospital; Assistant
Clinical Professor, St. Joseph's Hospital,
Milwaukee
* Case Study Coordinator
Philadelphia
Carla Campbell, MD, Medical Director,
Lead Poisoning and Toxicology Clinic,
Children's Hospital of Philadelphia;
Pediatric Consultant, Philadelphia
Department of Health
*Lisa Donahue, Environmental Scientist,
EPA Region III, Philadelphia
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*Karen Johnson, Chief, Safe Drinking Water
Act Branch, Office of Compliance and
Enforcement, EPA Region III, Philadelphia
Richard Tobin, Program Director,
Philadelphia Childhood Lead Poisoning
Prevention Program
* Case Study Coordinator
Minnesota
Terri Helland, RN, Public Health Nurse,
Brown County Public Health
Anita Hoffmann, Director, Brown County
Public Health
*Bonnie Holz, Public Health Preparedness
Coordinator, Minnesota Department
of Health; formerly Environmental
Health Director for Brown, Nicollet and
Cottonwood Counties
Kevin Kuehner, Water Quality Specialist,
Brown Nicollet Cottonwood Water
Quality Board
* Case Study Coordinator
Physician, Nurse, and Health
Educator Reviewers
The following people helped ensure the activity
met criteria required for a continuing education
activity within their professions.
Brenda Afzal, RN, BSN, MS, Project Manager,
University of Maryland School of Nursing,
Environmental Health Education Center
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John M. Balbus, MD, MPH
Diane Drew, RN, Senior Health Education
Specialist, CDC
Cathey E. Falvo, MD, MPH, Professor of
Public Health Practice, Clinical Associate
Professor of Pediatrics, New York Medical
College
Sharon Hall, RN, Public Health Advisor,
Acting Branch Chief, Learner Support,
CDC
Barbara Sattler, RN, DrPH, Associate
Professor and Director, Environmental
Health Education Center, University of
Maryland School of Nursing
Lauren Swirsky, MPH, CHES, Senior Health
Education Specialist, Division of Health
Education, ATSDR
Dianyi Yu, MD, PhD, Medical Officer, CDC
Special Thanks
In addition to workplaces of the experts
interviewed, the following organizations have
contributed video footage, still images, or filming
locations to this production:
Fairmount Water Works Interpretive Center,
Philadelphia Water Department
Georgetown Aqueduct in Washington, DC,
operated by the U.S. Army Corps of
Engineers
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School District of Philadelphia
Mulberry Child Care & Preschool,
Philadelphia
CH Diagnostic & Consulting Services, Inc.,
Loveland, Colorado
U.S. Department of Agriculture, Soil
Conservation Service
Thank you to all those who participated in pilot
testing, and to staff at EPA, CDC, and ATSDR,
too numerous to list, who reviewed multiple drafts
and provided valuable critiques and advice.
Finally, thank you to all those involved, on- and
off-camera, in the production of this video.
The Milwaukee segment was filmed the week
of September 11, 2001, and the Philadelphia
and Minnesota segments were filmed just a few
weeks later. The hospitality and commitment
of our hosts, and the diligence, support, and
professionalism of the DC-based crew, made this
production possible and will not be forgotten.
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Office of Ground Water and
Drinking Water (4606-M)
EPA816-K-04-001
www.epa.gov/safewater
August 2004
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