Reporting Waterborne Disease Outbreaks

Cooperation between water systems and healthcare facilities within their service areas can help prevent waterborne disease and detect potential outbreaks early to minimize harm. The following information outlines the basics for how to recognize and report waterborne disease outbreaks (WBDOs). 

What are waterborne disease outbreaks?

Waterborne disease outbreaks (WBDO) can be categorized by etiologic agent (the organism making people sick), type of water use (drinking, recreational, other), routes of entry (ingestion, inhalation, intranasal, or skin contact) and means of water contamination.

WBD agents may cause gastrointestinal, skin, respiratory or systemic illness. Symptoms may include abdominal cramps, vomiting, diarrhea, hives, rashes, irritated eyes, sore throat, pneumonia, or systemic illness.

Purpose of Reporting and Monitoring

• To detect WBDOs that can be controlled with appropriate public health measures (boil or bottled water advisory, pool closure). 
• To confirm the type of WBDO, thereby guiding treatment and control measures to prevent further exposures and additional cases of illness. 
• To assess whether implemented control measures are effective in stopping further transmission.
• To expand current understanding of the transmission, pathogenesis, and community impact of illness caused by WBD agents. 
• To identify new WBD agents, hazards, or gaps in the water safety system.

Responding and Reporting

What actions can health facilities take?

In most instances, consult with state/local environmental and public health staff, who can provide situation specific guidance and assist an owner/operator in treating water and cleaning the facility as needed.  With guidance from environmental health staff, immediate control measures could include (but are not limited to) the following:

• Drinking water: Issuing a boil or bottled water advisory, recalling a commercial product like bottled water
• Recreational water: Closing a facility or beach, posting warning signs at a lake, super-chlorinating pool water, backwashing the filter, draining the water, sanitizing the bathrooms or other likely-contaminated areas, cleaning the entire facility, and refilling the water and treating the water as required or feasible (for treated water facilities)
• Any water source: Issuing a press release to advise citizens who may develop illness

How to report the event?

• Water systems and local public health departments: Report known or suspected WBDO to CDPHE immediately upon receiving a report of a known or suspected outbreak. CDPHE will review the situation with you and assist if there is agreement that an investigation is needed.
• Health care facilities: Immediately notify your local health jurisdiction of outbreaks or suspected outbreaks.
• Per statute 6 CCR 1009-1, appendix A: "Outbreaks - known or suspected of all types - including those transmitted from food, water, person-to-person, and related to a healthcare setting." 

Who to contact at the department?

• Contact the department’s 24-hr emergency line: 1-877-518-5608. 
• Call as soon as possible but no later than 10 a.m. of the day following the incident.
• CDPHE Communicable Diseases
• 303-692-2700
• 303-370-9395 (after hours only)
• CDPHE Toxicology Line
• ToxCall 303-692-2606, cdphe_toxcall@state.co.us
• ToxCall is a good resource if toxic algae is suspected

Additional details including what information to include when you report an incident and what to expect after reporting can be found here.

➽  Chelsea Cotton Source Water & Emerging Contaminant Engineer

Emergency Response Plans and Security Considerations

America's Water Infrastructure Act (AWIA)

America’s Water Infrastructure Act (AWIA) passed Congress and was signed into law in 2018 to improve drinking water and water quality, deepen infrastructure investments, enhance public health and quality of life, increase jobs, and bolster the economy. The AWIA provisions are the most far-reaching changes to the Safe Drinking Water Act since the 1996 Amendments, with over 30 mandated programs. One aspect of this federal act was the Community Water System Risk and Resilience Assessments aimed at community water systems serving more than 3,300 people. These water systems are required to develop or update risk assessments and emergency response plans (ERPs). The law specifies the components that the risk assessments and ERPs must address, and establishes deadlines by which water systems must certify to EPA completion of the risk assessment and ERP. 

Where do we stand with AWIA requirements now?

Many of the AWIA risk and resilience assessments and emergency response plan deadlines have come and gone for larger systems. However for systems serving populations ranging from 3,301 to 49,999 the deadline to certify that your emergency response plan has been completed or updated is December 20, 2021. 

POPULATION SERVED	RISK ASSESSMENT PLAN	EMERGENCY RESPONSE PLAN
Greater than 100,000	March 31, 2020	by Sept. 30, 2020
50,000 to 99,999	Dec. 31, 2020	by June 30, 2021
3,301 to 49,999	June 30, 2021	by Dec. 20, 2021

Special Considerations - Security 

Recently, special attention has been paid to increasing the importance of security planning within general emergency response plans. And with good reason, 2021 alone has demonstrated that drinking water infrastructure is susceptible to cyberattacks which have potentially catastrophic results. Many small to medium systems may think that they are not susceptible to cyberattack. However, many cybercriminals are moving to attack smaller systems because they know there are less barriers in place to prevent attacks. The division encourages you and your system to incorporate robust cybersecurity measures into your emergency response plan. Please see the below resources to help you in these vital efforts. 

Resources

• EPA's AWIA - Risk Assessments and Emergency Response Plans: Information and training needed to complete a successful risk assessment and ERP, along with deadlines and how-to guidance.
• Water Information Sharing and Analysis Center: Free webinars to educate operators and drinking water system owners on AWIA requirements.
• CDPHE Drinking Water Security Response Toolbox: This toolbox is designed to help water utilities plan for, prevent, and guide responses to security threats including general malevolent acts, cyberattacks, tampering, and violent acts.
• WQCD Free One-on-one Assistance: Free one-on-one coaching at your facility to meet your specific needs. Training units are available, depending on time spent with the coach.

➽ Kyra Gregory Drinking Water Coach 

PFAS: EPA roadmap and Possible sources database from EPA

Resources: 

• Click here to view the EPA roadmap
• Click here for more information about the PFAS bills and get involved in the stakeholder process to create a certificate of registration program

On October 18, 2021, EPA Administrator Michael S. Regan announced the agency’s PFAS Strategic Roadmap which entails how the EPA will address the issue of PFAS. PFAS are man-made chemicals that have properties that make them useful for consumer and industrial use, but also make them persistent in the environment. PFAS chemicals from firefighting foam, personal products, and other substances are toxic and can move into the groundwater and surface water, contaminating Colorado’s drinking water supplies. There is evidence that exposure to PFAS can lead to adverse human health effects including low infant birth weights, cancer and effects on the immune system.

The actions EPA plans to take with their PFAS Strategic Roadmap from 2021 through 2024 are guided by three goals to address PFAS:

• Research: Invest in research, development, and innovation to increase understanding of PFAS exposures and toxicities, human health and ecological effects, and effective interventions that incorporate the best available science.
• Restrict: Pursue a comprehensive approach to proactively prevent PFAS from entering air, land, and water at levels that can adversely impact human health and the environment. 
• Remediate: Broaden and accelerate the cleanup of PFAS contamination to protect human health and ecological systems.

The department supports key actions in the EPA’s newly released PFAS roadmap, including their efforts to develop regulatory limits for PFAS in drinking water ahead of their statutory deadline. They propose a draft rule in fall 2022 with a final rule in fall 2023.

Additionally, the EPA identified more than 120,000 facilities that may expose the public to PFAS. Colorado was at the top of the list for states with potential PFAS sources. It’s important to remember a few things about potential sites identified in Colorado:

• The data represents facilities in industries that may handle PFAS chemicals. This does not necessarily mean that every location identified is handling PFAS chemicals, or that PFAS has ever been released into the environment from these sites.
• Identifying where we have releases of PFAS in the environment that impact drinking and irrigation water is a top priority for CDPHE.
• These potential sources do not tell us whether people have been exposed to levels that might harm their health. We are developing a potential vulnerability map to further investigate drinking water sources that have the potential to be impacted and our upcoming grant program will support further testing. 
• Colorado’s oil and gas regulations are more restrictive than many other states, which may result in more facilities reporting to the EPA. This could be a reason why Colorado has been identified as having more potential PFAS sites than other states.

The state continues to address PFAS issues through House Bill 20-1119 and Senate Bill 20-218. A PFAS Takeback Program launched in September to pay Colorado fire departments to take firefighting foam containing these chemicals out of service and have them safely stored until we can properly dispose of it. The grant program for Senate Bill 20-218 will launch later this fall and will provide funding opportunities for sampling efforts to test groundwater and surface water, water treatment infrastructure, and support emergency assistance for communities and water systems affected by these chemicals. Drinking water providers will be able to use this funding opportunity to test their treated drinking water and source water. 

➽ Sierra Mitchell, PFAS Program Coordinator

Lead Service Line Inventories and Private Property and Access Concerns

After a recent Aqua Answers article about the difference between lead service line inventories and materials evaluations, several water operators raised questions about the feasibility of completing the activities due to access issues and private property concerns. 

Let’s start with a primer on the requirements for a lead service line inventory under the Lead and Copper Rule Revisions, likely to be finalized in December of 2021. It is almost guaranteed that by the end of 2024, suppliers will be required to create at least an initial lead service line inventory for their system, with ongoing updates required as well. Each service line, including both the utility and private side, would need to be evaluated and categorized as having lead, galvanized downstream of lead, non-lead, or unknown. 

It’s important to note that physical verification at all service lines is not required and not expected. Suppliers should consider all available information before determining physical verification is warranted. This includes reviewing any installation records, building codes or ordinances dictating the service line material. In addition, observations of line materials when doing maintenance and repair at water mains or along the service line can be used. For example, if an external meter pit has copper or PEX on both sides of the yoke, this material is likely running from the corp or curb stop, depending on the location of the meter pit, and to the building. 

While lead service lines weren’t banned until 1986, their use was falling out of favor in the late 1940s. The latest known lead service line installation in Colorado based on reported information to the department is currently 1956. Therefore, the department would accept with high probability that unknown service lines installed after 1955 with some supporting records or observations can be categorized as non-lead in the lead service line inventory. This date cutoff should greatly limit the scope of a system’s investigation. 

For unknown service lines installed before 1955, suppliers can still categorize the materials without physical verification if there are any records on installed material type or there were ordinances banning lead materials. While there may be illegal installations or deviations in listed materials used, there is a high probability that lead materials were not used if there were records or standing ordinances.  

Even if there are remaining unknown service lines, these service lines are not all required to be physically verified. In the absence of EPA guidance and expectations for states, the department currently supports Michigan’s approach to lead service line inventory as they undertake a state-specific lead service line replacement program. Their verification effort requires that 20% of unknown service lines be randomly selected for verification to create a statistically sound, probabilistic determination of service line material as lead, galvanized downstream of lead, or non-lead. Please note that physical verification only pertains to the remaining unknown service lines. For example, if you have 100 total service line connections, and you determine with high probability through installation dates, records, and observations that 80 are likely non-lead, then you would have 20 remaining unknown service lines, leaving a minimum of 4 (20% of 20) to be physically verified.

Michigan’s approach on physical verification is to conduct three or four points of inspection that includes:

• The interior portion of the service line up to the first shutoff valve, usually the main shut off valve located in a wall cutout or in a crawlspace, 

• The line from the building to the curb stop, 

• The line from the curb stop to the water main, and

• If present, the gooseneck or pigtail connector at the water main.

The points to target for physical verification may vary depending on the layout of components along the service line. For in-ground physical verification, suppliers may utilize hydrovacuum excavation, air-knifing, trenching, or hand digging to inspect the material. If there were controls on materials for a portion of the service line then physical inspection at that point in the line is not warranted. For example, if the utility has records or had mandates on the utility-owned portion of the line, but the homeowner was responsible for selecting their material, only the customer side would have to be physically verified. 

Now we get to the crux of the problem: disturbing the ground on private property or requesting access from the homeowner to the inside of a home. These bring up sensitive issues and safety concerns for suppliers as they interact with their customers. First let’s discuss options related to the interior portion. If the homeowner does not allow access or the supplier wishes not to enter a home for safety reasons, the supplier can ask the homeowner to take a photo of the pipe material entering their home or at the main water shutoff to share with the supplier. Additionally, the supplier can provide a magnet to help determine the difference between similar appearing lead pipe and galvanized steel, as a magnet will not be attracted by lead. For exterior verification, you may need to explain the importance of this one-time verification and, if necessary, provide an incentive on their water bill for the disturbance to their ground. Based on feedback from utilities in other states, the new rule will be quite onerous to systems with lead service lines after 2024 and some systems are considering replacing a customer’s lead service line for them if found. If the system is willing to bear this cost to minimize future requirements, this cost incentive as well as public health protection could be shared with a homeowner who is reluctant to participate.

It’s important to note that if a homeowner refuses to cooperate, the supplier may move to the next randomly selected customer to see if they are willing to participate. Even if a supplier is unable to verify the material of their unknown service lines to make a probabilistic determination, there is a provision in the rule that allows the supplier to continue to list these sites as unknown in their inventory. However, in this case, the supplier has to assume the unknown service lines likely contain lead and will have to conduct ongoing special notices to these customers about the health effects of lead and prepare a lead service line replacement program for the sites, if ever triggered by the rule. Lastly, these sites would not be sampled for compliance under the new rule, due to the lack of confirmation on materials.

In conclusion, the department hopes that this more thorough description of what’s required of a lead service line inventory shows that it is not expected that every service line be physically verified as long as there is supporting documentation that gives the supplier high confidence on the materials at each line. Homeowner access is a touchy subject for suppliers and may mean some difficult conversations, but failure to gain access will not put the system out of compliance, as long as a credible effort to gain inventory information takes place. We recommend that utilities work with their customers and help them understand the importance of assisting with this process and the risks of lead in drinking water for both children and adults. As always, we are happy to discuss and help. Once the lead and copper rule revisions are final, we will be working with EPA to develop guidance for water systems that includes a reasonable approach to meet the lead service line inventory requirement.

➽ Bryan Pilson Technical, Regulatory Implementation, and Coordination Unit Manager

Coming Down the Pipe: Reg. 11 Backflow Guidance Updates

Please see updates on the division’s webpage

In early 2021, we ran a stakeholder process to update policies both for backflow prevention and cross connection control as well as storage tank regulations. After those updated policies were published, we began an effort over the summer to update guidance materials for both rules. We prioritized the backflow prevention and cross connection control guidance materials because more systems are struggling with them.

• In early October, we published the first in the series of several guidance documents for stakeholder review and comment - the backflow prevention and cross connection control annual reporting template for community water systems - available on the webpage. 

• The stakeholder community has valuable insight and we would like to receive stakeholder feedback about the template. Please navigate to the page above and review the annual report template. The deadline to provide feedback to the division is November 20. 

Professionalism and the Colorado Certified Water Professional Code of Conduct

For the past several years, the Colorado Certified Water Professionals (CCWP) Program has been experiencing what some might call growing pains. The transition to the CCWP Portal was traumatic to some operators and a relief to others. Some are still figuring it out. What has been a little more subtle than the CCWP Portal is the growing emphasis on professionalism. To acknowledge that there is more going on than simply “operation,” operators are referred to as “certified water professionals.” Many facilities now utilize electronic monitoring and data collection. Certified water professionals need to be computer literate, as well as able to apply biological and chemical principles to transform raw water into safe water for drinking and/or recreation. They need to use mathematical equations to calculate appropriate chemical dosages, flows, pressure, etc. The qualifications for certification, (including education, experience, on-going training and sufficient knowledge to pass a specialized examination) separate certified water professionals from less skilled workers.

For these reasons, in 2018, the Water and Wastewater Facility Operators Certification Board (board) adopted the Colorado Certified Water Professionals Code of Conduct, to which every applicant for certification or certificate renewal must agree.

A code of conduct clarifies a profession’s mission, values and principles. It is both an internal guideline and an external statement of values and commitments. Internally, a written code of conduct provides benchmarks against which individual performance can be measured. Externally, it serves as a public statement of the profession’s commitment to high standards and proper conduct.

The Colorado Certified Water Professional Code of Conduct emphasizes the profession’s commitment to protecting public health and the environment. It holds certified water professionals to standards of behavior that include honesty, excellence, responsibility and compliance with state and federal laws, rules, regulations and permits. At all times, certified water professionals are expected to use their knowledge to help safeguard water quality for Colorado residents and visitors.

The importance of this professional code is underscored by the fact that every certified water professional must agree to it. Failure to follow the code of conduct can be grounds for disciplinary action by the board. If you haven’t reviewed the Colorado Certified Water Professional Code of Conduct lately, take a couple of minutes to do so now.

➽ Nancy Horan, Facility and Operator Outreach and Certification Board Liaison