Walkerton - Five Years After

Lessons learned in the aftermath of Canada's worst E. coli Contamination

Five years ago, the small, rural community of Walkerton, Ontario, Canada fell victim to a devastating outbreak of waterborne disease that caused seven deaths and more than 2,300 illnesses. A result of cattle manure washing into a shallow water supply well, the 2000 outbreak revealed serious flaws in the municipality's drinking water system and raised concerns about the management of public water sources across Canada. Walkerton's water system managers recently pleaded guilty to criminal charges, closing five years worth of investigation. However, many factors contributed to the Walkerton tragedy, highlighting the need for constant vigilance and multiple layers of protection to ensure safe community water supplies.

The government of Ontario established an independent "Commission of Inquiry" to document events surrounding the Walkerton outbreak and to suggest preemptive reforms for other water systems in the province. The inquiry, conducted by Justice Dennis O'Connor, led to scrutiny of Walkerton water system operators and, eventually, to criminal charges for their roles in the outbreak. Justice O'Connor's report concluded that for years, Walkerton operators had failed to use adequate doses of chlorine, failed to test chlorine residual levels daily as required, and falsified log entries and annual reports. During the period of contamination beginning May 12, operators failed to check residual levels for a period of several days, allowing unchlorinated water to enter the distribution system. In their recently concluded trial, Walkerton utilities manager Stan Koebel and his brother Frank pleaded guilty to a charge of "common nuisance" for failing to monitor and treat the town's water supply properly. As part of a plea bargain, prosecutors dropped more serious charges of breach of trust and falsifying documents.

As Health Stream reported in March 2002, "Daily monitoring would have revealed the lack of chlorine residual caused by the increased chlorine demand of the contaminated water, and steps to protect public health could have been initiated." Instead, erroneous, community-wide prognoses were made, exacerbating the crisis. Beginning on May 18th, when residents began falling sick, food poisoning was the suspected cause and, ironically, sufferers were being advised by doctors to avoid dehydration and drink plenty of water. It was not until May 21st that contaminated well water was confirmed as the cause and a 'boil-water alert' was issued.

Two days later, lab results identified the presence of Campylobacter bacteria and E. coli 0151:H7, a strain of E. coli bacteria that produces a powerful toxin and can cause severe illness. DNA testing identified the contaminating source as a cattle farm a short distance from Well 5. Experts confirmed that heavy rainfall carried manure from the cattle farm close enough to permeate and corrupt the water source.

The precarious location of the well, however, had been noted prior to 2000. As far back as 1978, reports prepared for the Walkerton Public Utilities Commission (PUC) referenced the Well 5's susceptibility to surface water influence and its resultant need for nearly continuous testing. These and other directives fell under the purview of PUC managers more than operators, and went largely disregarded. In retrospect, it is particularly unfortunate that conditions normally evaluated as an actionable vulnerability were left to languish. What was a manageable situation instead created the risky conditions that, ultimately, became a public health tragedy.

Walkerton is almost entirely dependent on groundwater for its domestic water supply and, beginning in 1949, deep wells were constructed for municipal service. In May 2000, the PUC was running three groundwater sources (Well 5, Well 6 and Well 7) though only one, Well 5, was operational -- it was, thus, the town's sole water source. Like any groundwater supply, the contents must be monitored regularly to ensure clean water and community health safety. Regulations dictate that water suppliers are required to treat groundwater with chlorine to sufficiently neutralize contaminants and sustain a chlorine residual of 0.5 mg/L of water after 15 minutes of contact. Had utility operators adhered to protocol, disaster most likely would have been averted.

Perhaps the most serious flaw in the Walkerton waterworks, however, was management neglect. Employees charged with major responsibilities in the water supply system received no formal training, had passed no examination and held no operator certification. Consequently, Justice O'Connor issued several recommendations:

• Funding was insufficient.
  It was found that Walkerton's municipal budget was providing inadequate funds for public utility oversight and unduly limiting proactive oversight measure, which may have either mitigated or altogether avoided the outbreak.
• Training was inadequate.
  In addition to thorough oversight, water operators must be properly trained and screened for competence, diligence and motivation and programs to further these ends should be endorsed.
• Details were overlooked.
  Records and logbooks needed be expanded to account for a wider range of detailed analysis and more frequent verification. Properly implemented oversight procedures ensure that efforts by both operators and managers are focused, and vulnerable areas, such as Walkerton's Well 5, are monitored vigilantly.
• Environmental factors were not considered.
  Groundwater sources must be managed with an appreciation for their surrounding environments, topography and land uses.
• Multiple protection barriers are needed
  Ensuring the health safety of drinking water wells must be approached from several angles. Beyond the first priority of selecting reliable, high-quality drinking water sources in the development of a drinking water well, regulations for well construction, maintenance and inspections must be enforced to protect drinking water from surface water infiltration and contamination.

Five years later, the truth about what happened at Walkerton has finally emerged and the picture that has come into focus is one each of us can appreciate. While it was one incident in one town in one country, the troubling lesson of Walkerton is that it could happen anywhere. Given the right conditions of inattention, mismanagement and lack of understanding by those in charge, a hazardous outbreak could be visited upon any community. As would be expected, the public health tragedy that occurred in Walkerton still haunts the town. Yet, much was learned, both by both by Canadian water officials and municipal water facilities operators and managers across North America. One message, perhaps above all else is made clear by the events of 2000: our public waters are our most valued and vulnerable public resource. Investment in keeping them safe and secure needs to be a community's first priority.